Provider Demographics
NPI:1558989616
Name:DAGENHART, LARRY JR (LMFT)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:DAGENHART
Suffix:JR
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10620 PARK RD STE 208
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-0106
Mailing Address - Country:US
Mailing Address - Phone:704-360-3637
Mailing Address - Fax:
Practice Address - Street 1:10620 PARK RD STE 208
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-0106
Practice Address - Country:US
Practice Address - Phone:704-360-3637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-06
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2335106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist