Provider Demographics
NPI:1356648257
Name:LARSON, STEPHANIE LYNN (MA)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:LYNN
Last Name:LARSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 W 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-3758
Mailing Address - Country:US
Mailing Address - Phone:541-868-0661
Mailing Address - Fax:
Practice Address - Street 1:1790 W 11TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-3758
Practice Address - Country:US
Practice Address - Phone:541-868-0661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-12
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health