Provider Demographics
NPI:1598345274
Name:MARSHALL, LARIDSA
Entity type:Individual
Prefix:
First Name:LARIDSA
Middle Name:
Last Name:MARSHALL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 W CAMERON AVE STE 215
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2724
Mailing Address - Country:US
Mailing Address - Phone:323-302-9997
Mailing Address - Fax:818-736-4189
Practice Address - Street 1:1501 W CAMERON AVE STE 215
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2724
Practice Address - Country:US
Practice Address - Phone:323-302-9997
Practice Address - Fax:818-736-4189
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst