Provider Demographics
NPI:1043362809
Name:ROLAND, LARRY (MS, LPC, LMFT)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:ROLAND
Suffix:
Gender:M
Credentials:MS, LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 263
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-0263
Mailing Address - Country:US
Mailing Address - Phone:503-789-9109
Mailing Address - Fax:
Practice Address - Street 1:1073 OAK ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4018
Practice Address - Country:US
Practice Address - Phone:503-585-4949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC0573101YM0800X
ORT0256106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist