=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669740544
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROSA ISELA LARIOS M.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2011
-----------------------------------------------------
Last Update Date | 04/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2450 S ATLANTIC BLVD SUITE 101
-----------------------------------------------------
City | COMMERCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90040-1200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-318-9960
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3060 PANORAMA RD APT 9
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92506-1400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-722-0574
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 66891
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 106088
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------