Provider Demographics
NPI:1346686342
Name:NYLUND, LARS CHRISTIAN (MA)
Entity Type:Individual
Prefix:
First Name:LARS
Middle Name:CHRISTIAN
Last Name:NYLUND
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SAINT VINCENTS DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1504
Mailing Address - Country:US
Mailing Address - Phone:415-507-2000
Mailing Address - Fax:
Practice Address - Street 1:2227 CAPRICORN WAY STE 207
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5486
Practice Address - Country:US
Practice Address - Phone:707-890-0425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-16
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT119706106H00000X
CAAMFT111396101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist