Healthcare Provider Details

I. General information

NPI: 1629851910
Provider Name (Legal Business Name): LARISSA MONTALVO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2023
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 PARAMOUNT BLVD STE 306
DOWNEY CA
90241-3324
US

IV. Provider business mailing address

248 SAN JUAN AVE
VENICE CA
90291-3730
US

V. Phone/Fax

Practice location:
  • Phone: 562-821-1491
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: