Provider Demographics
NPI:1346512944
Name:LARSON, GUY
Entity Type:Individual
Prefix:MR
First Name:GUY
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 LARKIN AVE
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-6042
Mailing Address - Country:US
Mailing Address - Phone:847-695-5656
Mailing Address - Fax:847-695-0897
Practice Address - Street 1:474 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-3829
Practice Address - Country:US
Practice Address - Phone:847-608-2682
Practice Address - Fax:847-608-2689
Is Sole Proprietor?:No
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health