Provider Demographics
NPI:1225253206
Name:STOLER, LARRY SCOTT (PHD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:SCOTT
Last Name:STOLER
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 1:2522 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:773-296-6700
Mailing Address - Fax:773-296-1131
Practice Address - Street 1:2522 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614
Practice Address - Country:US
Practice Address - Phone:773-296-6700
Practice Address - Fax:773-296-1131
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK49576Medicare PIN