Healthcare Provider Details

I. General information

NPI: 1720910672
Provider Name (Legal Business Name): MARISSA LARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 ROSE DR
BENICIA CA
94510-3761
US

IV. Provider business mailing address

273 W I ST
BENICIA CA
94510-3118
US

V. Phone/Fax

Practice location:
  • Phone: 707-747-8390
  • Fax:
Mailing address:
  • Phone: 707-747-8330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberB9695071
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: