Healthcare Provider Details

I. General information

NPI: 1629614144
Provider Name (Legal Business Name): LARISA BECKWITH PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LARISA EVANS PSYD

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 03/26/2020
Certification Date: 03/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

764 FAXON AVE
SAN FRANCISCO CA
94112-1204
US

IV. Provider business mailing address

764 FAXON AVE
SAN FRANCISCO CA
94112-1204
US

V. Phone/Fax

Practice location:
  • Phone: 310-562-4048
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPSY17813
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY17813
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberPSY17813
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY17813
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: