Provider Demographics
NPI:1437557972
Name:LARSON, RODNEY I (MACC)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:
Last Name:LARSON
Suffix:I
Gender:M
Credentials:MACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2545 LAWRENCEVILLE HWY
Mailing Address - Street 2:SUITE 150
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-3239
Mailing Address - Country:US
Mailing Address - Phone:678-332-1221
Mailing Address - Fax:
Practice Address - Street 1:8097 ROSWELL RD
Practice Address - Street 2:SUITE C101
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30350-6159
Practice Address - Country:US
Practice Address - Phone:678-332-1221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-16
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009039101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALPC009039OtherLICENSED PROFESSIONAL COUNSELOR