Provider Demographics
NPI:1376553503
Name:LARSON, MARK DOUGLAS (DMIN, LPC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DOUGLAS
Last Name:LARSON
Suffix:
Gender:M
Credentials:DMIN, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2935 FOREST PARK DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-1401
Mailing Address - Country:US
Mailing Address - Phone:704-334-7543
Mailing Address - Fax:
Practice Address - Street 1:605 EAST BOULEVARD
Practice Address - Street 2:METHODIST COUNSELING & CONSULTATION SERVICES
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5111
Practice Address - Country:US
Practice Address - Phone:704-375-5354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2189101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional