MEDICARE: LARISSA CLEMONS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker

General Provider Information

NPI Number	:	1386584837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARISSA CLEMONS

Provider Business Mailing Address
First Line	:	943 NASH AVE
Second Line	:
City	:	YPSILANTI
State	:	MI
Zip	:	48198-8023
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5770 HIGHLAND RD STE C
Second Line	:
City	:	WATERFORD
State	:	MI
Zip	:	48327-1877
Country	:	US
Telephone Number	:	313-903-3955
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2026
Last Update Date	:	04/01/2026

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