Provider Demographics
NPI:1154507648
Name:TITTLE, LARISSA A (MA, MFT)
Entity Type:Individual
Prefix:MS
First Name:LARISSA
Middle Name:A
Last Name:TITTLE
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 134
Mailing Address - Street 2:
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723-0134
Mailing Address - Country:US
Mailing Address - Phone:562-619-8291
Mailing Address - Fax:
Practice Address - Street 1:2309 PACIFIC COAST HWY STE 103
Practice Address - Street 2:
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-2752
Practice Address - Country:US
Practice Address - Phone:562-619-8291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-14
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 45186106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist