Provider Demographics
NPI:1518903566
Name:LARSON, LEOTA I (PHD LICENSE PSYCHOLO)
Entity Type:Individual
Prefix:DR
First Name:LEOTA
Middle Name:I
Last Name:LARSON
Suffix:
Gender:F
Credentials:PHD LICENSE PSYCHOLO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 S RIVER
Mailing Address - Street 2:SUITE 254
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548
Mailing Address - Country:US
Mailing Address - Phone:608-755-5260
Mailing Address - Fax:608-755-5267
Practice Address - Street 1:17 S RIVER
Practice Address - Street 2:SUITE 254
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548
Practice Address - Country:US
Practice Address - Phone:608-755-5260
Practice Address - Fax:608-755-5267
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1808103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist