Basic Information
| Provider Information | |||||||||
| NPI: | 1952923112 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | LARISSA | ||||||||
| MiddleName: | NOEL | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ERICKSON | ||||||||
| OtherFirstName: | LARISSA | ||||||||
| OtherMiddleName: | NOEL | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8884 GOLDEN LN | ||||||||
| Address2: | |||||||||
| City: | DE SOTO | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660187501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9139806004 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1501 INVERNESS DR | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660471870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858388000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2020 | ||||||||
| LastUpdateDate: | 05/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11-06367 | KS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.