1881794535 NPI number — THERESA M. LARSON LPC

Table of content: BRIAN HAWORTH PSYD (NPI 1043307176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881794535 NPI number — THERESA M. LARSON LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARSON
Provider First Name:
THERESA
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881794535
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6310 N LAKESHORE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSE SPRINGS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63051-1122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-805-4261
Provider Business Mailing Address Fax Number:
314-849-0159

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10004 KENNERLY RD
Provider Second Line Business Practice Location Address:
SUITE 362B
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63128-2141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-849-0450
Provider Business Practice Location Address Fax Number:
314-849-0159
Provider Enumeration Date:
09/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  002139 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 498662501 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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