Provider Demographics
NPI:1417923939
Name:HART, LARRY S (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:S
Last Name:HART
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 1:5319 SW WESTGATE DR
Mailing Address - Street 2:#147
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2430
Mailing Address - Country:US
Mailing Address - Phone:503-297-2019
Mailing Address - Fax:503-297-9496
Practice Address - Street 1:5319 SW WESTGATE DR
Practice Address - Street 2:#147
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2430
Practice Address - Country:US
Practice Address - Phone:503-297-2019
Practice Address - Fax:503-297-9496
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR629103T00000X
OR1374103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR068WCHXRCMedicare ID - Type Unspecified