Provider Demographics
NPI:1437683836
Name:LARSON, JUSTINA BETH
Entity Type:Individual
Prefix:
First Name:JUSTINA
Middle Name:BETH
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82871 LARSEN DR
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92203-4014
Mailing Address - Country:US
Mailing Address - Phone:760-485-3804
Mailing Address - Fax:
Practice Address - Street 1:82871 LARSEN DR
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92203-4014
Practice Address - Country:US
Practice Address - Phone:760-485-3804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106H00000XOtherMFT