Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC2200X | Clinical Child & Adolescent Psychologist | ||
N | 103TH0100X | Health Service |
NPI | 1053934612 |
---|---|
Provider Name | Kayla N Larosa |
First Address | Chicago, IL 60677-6879 |
Second Address | Louisville, KY 40202-1831 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/05/2020 |
Last Update Date | 23/10/2020 |