Basic Information
| Provider Information | |||||||||
| NPI: | 1962000919 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDONOUGH | ||||||||
| FirstName: | LARISSA | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2236 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057339782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027758224 | ||||||||
| FaxNumber: | 8027477699 | ||||||||
| Practice Location | |||||||||
| Address1: | 78 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RUTLAND | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057014594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027758224 | ||||||||
| FaxNumber: | 8027477699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2020 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 146.0134161 | VT | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.