Provider Demographics
NPI:1851441810
Name:MORICCA, LARRY SAMUEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:SAMUEL
Last Name:MORICCA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 POLLASKY AVE
Mailing Address - Street 2:#210
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-1875
Mailing Address - Country:US
Mailing Address - Phone:559-294-8197
Mailing Address - Fax:559-298-5378
Practice Address - Street 1:642 POLLASKY AVE
Practice Address - Street 2:#210
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-1875
Practice Address - Country:US
Practice Address - Phone:559-299-5451
Practice Address - Fax:559-298-5378
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7595103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OOPL75950Medicare ID - Type Unspecified