Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 08/18/2023
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1990 WESTWOOD BLVD STE 360
LOS ANGELES CA
90025-4650
US

IV. Provider business mailing address

248 SAN JUAN AVE
VENICE CA
90291-3730
US

V. Phone/Fax

Practice location:
  • Phone: 424-201-1600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number36748
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: