Provider Demographics
NPI:1326003344
Name:LARSON, ERIC JOHN (EL CADC BS)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:JOHN
Last Name:LARSON
Suffix:
Gender:M
Credentials:EL CADC BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 E EUREKA
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:IL
Mailing Address - Zip Code:61530
Mailing Address - Country:US
Mailing Address - Phone:309-467-3770
Mailing Address - Fax:309-467-5356
Practice Address - Street 1:109 E EUREKA
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:IL
Practice Address - Zip Code:61530
Practice Address - Country:US
Practice Address - Phone:309-467-3770
Practice Address - Fax:309-467-5356
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14471101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)