Provider Demographics
NPI:1437812211
Name:MARK T. LARSEN, LPC LLC
Entity Type:Organization
Organization Name:MARK T. LARSEN, LPC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:276-698-5595
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty