Provider Demographics
NPI:1396824934
Name:LARSEN, MARK TIMOTHY (LPC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:TIMOTHY
Last Name:LARSEN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 NOTTINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-1412
Mailing Address - Country:US
Mailing Address - Phone:276-698-5595
Mailing Address - Fax:
Practice Address - Street 1:170 NOTTINGHAM DR
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1412
Practice Address - Country:US
Practice Address - Phone:276-698-5595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004045101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional