Basic Information
| Provider Information | |||||||||
| NPI: | 1114946886 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HORNER | ||||||||
| FirstName: | LARISSA | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 JACKSON PIKE | ||||||||
| Address2: | |||||||||
| City: | GALLIPOLIS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456311560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404411934 | ||||||||
| FaxNumber: | 7404465982 | ||||||||
| Practice Location | |||||||||
| Address1: | 98 STATE ST | ||||||||
| Address2: | |||||||||
| City: | PROCTORVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456698163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7408869403 | ||||||||
| FaxNumber: | 7404465153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 10/07/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 068615 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 006815 | WV | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 650019667 | 01 | RR MEDICARE | OTHER | 2221287 | 01 | OH | MOLINA MEDICAID | OTHER | 0157960000 | 05 | WV | MEDICAID | 000000204524 | 01 | OH | OH MEDICAID UNISON | OTHER | 000000217253 | 01 | ANTHEM BCBS | OTHER | 2221287 | 05 | OH | MEDICAID |