Provider Demographics
NPI:1114213295
Name:LARGE, STEPHEN J (PSYD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:J
Last Name:LARGE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:542 W 6TH ST
Mailing Address - Street 2:# 3
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1169
Mailing Address - Country:US
Mailing Address - Phone:937-212-3845
Mailing Address - Fax:
Practice Address - Street 1:542 W 6TH ST
Practice Address - Street 2:# 3
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1169
Practice Address - Country:US
Practice Address - Phone:937-212-3845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS016742103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical