Provider Demographics
NPI:1528590957
Name:LARRY, TANYA (LMFT)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:LARRY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 CALLAWAY CIR
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-4521
Mailing Address - Country:US
Mailing Address - Phone:601-942-1884
Mailing Address - Fax:
Practice Address - Street 1:2627 RIDGEWOOD RD
Practice Address - Street 2:STE 103
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4904
Practice Address - Country:US
Practice Address - Phone:601-942-1884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST0442106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist