Provider Demographics
NPI:1497027213
Name:LARRY M. KIRKLAND, INC.
Entity Type:Organization
Organization Name:LARRY M. KIRKLAND, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:KIRKLAND
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:850-323-1002
Mailing Address - Street 1:285 W LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WEWAHITCHKA
Mailing Address - State:FL
Mailing Address - Zip Code:32465-7525
Mailing Address - Country:US
Mailing Address - Phone:850-323-1002
Mailing Address - Fax:850-482-0015
Practice Address - Street 1:4435 MARION ST
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32448-4630
Practice Address - Country:US
Practice Address - Phone:850-482-0019
Practice Address - Fax:850-482-0015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8715101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001235600Medicaid