Provider Demographics
NPI:1235895343
Name:LARSON, ZACHARY (LMHC)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1980 HARBOR ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-7257
Mailing Address - Country:US
Mailing Address - Phone:904-600-7799
Mailing Address - Fax:
Practice Address - Street 1:1543 KINGSLEY AVE STE 14
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4570
Practice Address - Country:US
Practice Address - Phone:904-264-6977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH19880101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health