Basic Information
| Provider Information | |||||||||
| NPI: | 1780060087 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARISEY | ||||||||
| FirstName: | BENJAMIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 770 | ||||||||
| Address2: | |||||||||
| City: | ZACHARY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707910770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2253062000 | ||||||||
| FaxNumber: | 2256581282 | ||||||||
| Practice Location | |||||||||
| Address1: | 1798 HIGHWAY 1042 | ||||||||
| Address2: | |||||||||
| City: | GREENSBURG | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704414241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2253062097 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2015 | ||||||||
| LastUpdateDate: | 08/10/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 11772 | LA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.