Provider Demographics
NPI:1346946431
Name:LARSON, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
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 1:448 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-2466
Mailing Address - Country:US
Mailing Address - Phone:703-431-7055
Mailing Address - Fax:
Practice Address - Street 1:448 W OAK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-2466
Practice Address - Country:US
Practice Address - Phone:703-431-7055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.014135101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health