Provider Demographics
NPI:1043739915
Name:CICILA, LARISA NAN (PHD)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:NAN
Last Name:CICILA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3321 31ST ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-4619
Mailing Address - Country:US
Mailing Address - Phone:419-494-6122
Mailing Address - Fax:
Practice Address - Street 1:2535 CAMINO DEL RIO S STE 106
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3764
Practice Address - Country:US
Practice Address - Phone:619-940-7774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29432103TF0000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily