Provider Demographics
NPI:1487197562
Name:LARKIN, RUSSELL SR (MDIV, LPC)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:LARKIN
Suffix:SR
Gender:M
Credentials:MDIV, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 DOLLEY MADISON BLVD
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3019
Mailing Address - Country:US
Mailing Address - Phone:703-851-4513
Mailing Address - Fax:
Practice Address - Street 1:2135 KINGS GARDEN WAY
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22043-2593
Practice Address - Country:US
Practice Address - Phone:703-851-4513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-22
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701000579101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0701000579OtherDEPARTMENT OF HEALTH PROFESSIONS