Provider Demographics
NPI:1053196642
Name:BEATTY, LARYSSA SUE
Entity type:Individual
Prefix:
First Name:LARYSSA
Middle Name:SUE
Last Name:BEATTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 335
Mailing Address - Street 2:
Mailing Address - City:DELLROY
Mailing Address - State:OH
Mailing Address - Zip Code:44620-0335
Mailing Address - Country:US
Mailing Address - Phone:740-792-4011
Mailing Address - Fax:
Practice Address - Street 1:7 S ARCH ST
Practice Address - Street 2:
Practice Address - City:DELLROY
Practice Address - State:OH
Practice Address - Zip Code:44620-8301
Practice Address - Country:US
Practice Address - Phone:740-792-4011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator