Provider Demographics
NPI:1306028295
Name:LARSON, NATHAN (PSYD,, HSPP)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:PSYD,, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9106 N MERIDIAN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1884
Mailing Address - Country:US
Mailing Address - Phone:317-575-9111
Mailing Address - Fax:317-571-4470
Practice Address - Street 1:9106 N MERIDIAN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1884
Practice Address - Country:US
Practice Address - Phone:317-575-9111
Practice Address - Fax:317-571-4470
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042106A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200888350Medicaid
IN200888350Medicaid