Healthcare Provider Details

I. General information

NPI: 1104554898
Provider Name (Legal Business Name): LARISSA SEVERSON LMHC, CN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2022
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6126 NE BOTHELL WAY UPPR
KENMORE WA
98028-8939
US

IV. Provider business mailing address

2745 CALIFORNIA AVE SW APT 401
SEATTLE WA
98116-2515
US

V. Phone/Fax

Practice location:
  • Phone: 206-413-8308
  • Fax:
Mailing address:
  • Phone: 360-789-6071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: