Basic Information
| Provider Information | |||||||||
| NPI: | 1366671596 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRACE | ||||||||
| FirstName: | LARISSA | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 ROYALTY DR STE 180 | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097843200 | ||||||||
| FaxNumber: | 9098650730 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 ROYALTY DR STE 180 | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097843200 | ||||||||
| FaxNumber: | 9098650730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2009 | ||||||||
| LastUpdateDate: | 09/29/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | A116676 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | A116676 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No ID Information.