Healthcare Provider Details

I. General information

NPI: 1942642343
Provider Name (Legal Business Name): LARISSA A LUCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12763 N WATT LN UNIT B
SYLMAR CA
91342-4899
US

IV. Provider business mailing address

12763 N WATT LN UNIT B
SYLMAR CA
91342-4899
US

V. Phone/Fax

Practice location:
  • Phone: 951-295-5537
  • Fax:
Mailing address:
  • Phone: 951-295-5537
  • Fax: 951-295-5537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT93807
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: