Provider Demographics
NPI:1437339561
Name:LUCE, LARISSA MARY (DHSC IBCLC RD)
Entity Type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:MARY
Last Name:LUCE
Suffix:
Gender:F
Credentials:DHSC IBCLC RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7719 SOUNDERS TRL
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-6616
Mailing Address - Country:US
Mailing Address - Phone:781-690-0445
Mailing Address - Fax:
Practice Address - Street 1:7719 SOUNDERS TRL
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-6616
Practice Address - Country:US
Practice Address - Phone:781-690-0445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-108178174N00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q339701106Medicare UPIN