1669806246 NPI number — LARISSA FERNE ARCHULETA LCSW

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669806246 NPI number — LARISSA FERNE ARCHULETA LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ARCHULETA
Provider First Name:
LARISSA
Provider Middle Name:
FERNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669806246
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3862 S 2915 W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST HAVEN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84401-9865
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-678-3291
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
962 CHAMBERS ST STE 11
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH OGDEN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84403-5092
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-625-3700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  7756352-3501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 260022408 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 876000308007 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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