Provider Demographics
NPI:1396855474
Name:LARSEN, LARRY L (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:L
Last Name:LARSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 ANDOVER STREET
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810
Mailing Address - Country:US
Mailing Address - Phone:978-475-6622
Mailing Address - Fax:978-475-8436
Practice Address - Street 1:28 ANDOVER STREET
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810
Practice Address - Country:US
Practice Address - Phone:978-475-6622
Practice Address - Fax:978-475-8436
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA575103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0501735Medicaid
MA0501735Medicaid
04-2531165-0000Medicare UPIN