Provider Demographics
NPI:1629031570
Name:LARSEN, JUDITH ANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:ANNE
Last Name:LARSEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 JASON ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-8033
Mailing Address - Country:US
Mailing Address - Phone:617-268-1700
Mailing Address - Fax:617-268-1991
Practice Address - Street 1:58 OLD COLONY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-2406
Practice Address - Country:US
Practice Address - Phone:617-268-1700
Practice Address - Fax:617-268-1991
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4567103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALAW51382Medicare ID - Type UnspecifiedPSYCHOLOGIST