MEDICARE: MRS. LARISSA LYNN WHITTENBURG OTR/L, CLC

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	225X00000X	Occupational Therapist	120683	TX

General Provider Information

NPI Number	:	1861201477
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LARISSA LYNN WHITTENBURG OTR/L, CLC

Provider Business Mailing Address
First Line	:	1210 STATE HIGHWAY 70
Second Line	:
City	:	SWEETWATER
State	:	TX
Zip	:	79556-1728
Country	:	US
Telephone Number	:	325-725-8338
Fax Number	:

Provider Business Practice Location Address
First Line	:	1132 HICKORY ST
Second Line	:
City	:	COLORADO CITY
State	:	TX
Zip	:	79512-4912
Country	:	US
Telephone Number	:	325-728-5312
Fax Number	:

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

Provider Enumeration Date	:	01/07/2025
Last Update Date	:	01/07/2025

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