MEDICARE: MISS LARISSA IRKA MCCORMICK MS, BCBA, LBA

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	103K00000X	Behavior Analyst	LBA193	MD

General Provider Information

NPI Number	:	1407217110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS LARISSA IRKA MCCORMICK MS, BCBA, LBA

Provider Business Mailing Address
First Line	:	2910 EVERGREEN WAY
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-1020
Country	:	US
Telephone Number	:	410-530-0069
Fax Number	:

Provider Business Practice Location Address
First Line	:	2910 EVERGREEN WAY
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-1020
Country	:	US
Telephone Number	:	410-530-0069
Fax Number	:

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

Provider Enumeration Date	:	03/09/2016
Last Update Date	:	03/09/2016

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