Healthcare Provider Details

I. General information

NPI: 1841641586
Provider Name (Legal Business Name): LARISSA FRAVEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 S LAWE ST STE 1
APPLETON WI
54915-2419
US

IV. Provider business mailing address

1620 S LAWE ST STE 1
APPLETON WI
54915-2419
US

V. Phone/Fax

Practice location:
  • Phone: 920-915-0102
  • Fax: 920-481-3121
Mailing address:
  • Phone: 920-284-9676
  • Fax: 920-481-3121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5984-125
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5984-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: