Healthcare Provider Details

I. General information

NPI: 1679778567
Provider Name (Legal Business Name): LARISSA ANN SWEENEY MSCCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 NW BURNSIDE RD
GRESHAM OR
97030-3836
US

IV. Provider business mailing address

15734 SE HAWK CT
PORTLAND OR
97236-7879
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-9106
  • Fax: 503-215-9149
Mailing address:
  • Phone: 503-215-9106
  • Fax: 503-215-9149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number11610
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: