Provider Demographics
NPI:1114030574
Name:LARSON, MARY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 SHERMAN AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3798
Mailing Address - Country:US
Mailing Address - Phone:847-866-6621
Mailing Address - Fax:847-864-0948
Practice Address - Street 1:1830 SHERMAN AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3798
Practice Address - Country:US
Practice Address - Phone:847-866-6621
Practice Address - Fax:847-864-0948
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical