Provider Demographics
NPI:1518094382
Name:LARGE, JAMES BRENT
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:BRENT
Last Name:LARGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 MISSION ST APT 313
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-5822
Mailing Address - Country:US
Mailing Address - Phone:415-206-6535
Mailing Address - Fax:
Practice Address - Street 1:887 POTRERO AVE
Practice Address - Street 2:L-UNIT
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-2869
Practice Address - Country:US
Practice Address - Phone:415-206-6535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health