Provider Demographics
NPI:1184832495
Name:LARSON, DALE G (PHD)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:G
Last Name:LARSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SANTA CLARA UNIVERSITY
Mailing Address - Street 2:500 EL CAMINO REAL
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95053-0201
Mailing Address - Country:US
Mailing Address - Phone:408-554-4320
Mailing Address - Fax:408-554-2392
Practice Address - Street 1:1769 PARK AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-2029
Practice Address - Country:US
Practice Address - Phone:408-554-4320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA7753103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist