Provider Demographics
NPI:1255687190
Name:LARSON, LORI ANN
Entity Type:Individual
Prefix:MISS
First Name:LORI
Middle Name:ANN
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 SEQUOIA ST
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-2531
Mailing Address - Country:US
Mailing Address - Phone:209-538-8368
Mailing Address - Fax:
Practice Address - Street 1:1235 MCHENRY AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5370
Practice Address - Country:US
Practice Address - Phone:209-521-0063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)