Provider Demographics
NPI:1679778567
Name:SWEENEY, LARISSA ANN (MSCCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:LARISSA
Middle Name:ANN
Last Name:SWEENEY
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15734 SE HAWK CT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-7879
Mailing Address - Country:US
Mailing Address - Phone:503-215-9106
Mailing Address - Fax:503-215-9149
Practice Address - Street 1:270 NW BURNSIDE RD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3836
Practice Address - Country:US
Practice Address - Phone:503-215-9106
Practice Address - Fax:503-215-9149
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11610235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist