Provider Demographics
NPI:1073605440
Name:WILLETT, LARRY CARL (PHD LPC)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:CARL
Last Name:WILLETT
Suffix:
Gender:M
Credentials:PHD LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 GREEN VALLEY RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-7722
Mailing Address - Country:US
Mailing Address - Phone:336-292-1510
Mailing Address - Fax:336-292-0679
Practice Address - Street 1:600 GREEN VALLEY RD
Practice Address - Street 2:SUITE 204
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7722
Practice Address - Country:US
Practice Address - Phone:336-292-1510
Practice Address - Fax:336-292-0679
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1002101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
09347900OtherMAGELLA BEH HEALTH
NC6102901Medicaid
NC87441OtherBCBS