Provider Demographics
NPI:1083049506
Name:LARSON, WESLEY WILLARD (MS LMFT)
Entity Type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:WILLARD
Last Name:LARSON
Suffix:
Gender:M
Credentials:MS LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-4607
Mailing Address - Country:US
Mailing Address - Phone:435-752-1976
Mailing Address - Fax:435-755-6707
Practice Address - Street 1:190 E CENTER ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4607
Practice Address - Country:US
Practice Address - Phone:435-752-1976
Practice Address - Fax:435-755-6707
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT275193-3902101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT275193-3902OtherMENTAL HEALTH