Provider Demographics
NPI:1043957822
Name:BENSON, LARRISSA EVETTE
Entity type:Individual
Prefix:MRS
First Name:LARRISSA
Middle Name:EVETTE
Last Name:BENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-1102
Mailing Address - Country:US
Mailing Address - Phone:213-213-0100
Mailing Address - Fax:
Practice Address - Street 1:425 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1102
Practice Address - Country:US
Practice Address - Phone:213-213-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator