Provider Demographics
NPI:1063637940
Name:LARSON, LORI LYNN (MFT)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:LYNN
Last Name:LARSON
Suffix:
Gender:F
Credentials:MFT
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 1655
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:CA
Mailing Address - Zip Code:95634-1655
Mailing Address - Country:US
Mailing Address - Phone:530-417-5308
Mailing Address - Fax:
Practice Address - Street 1:6692 MERCHANDISE WAY
Practice Address - Street 2:STE. B
Practice Address - City:DIAMOND SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95619-9453
Practice Address - Country:US
Practice Address - Phone:530-626-2589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT36109106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist