Provider Demographics
NPI:1629248059
Name:LARRABEE, GLENN J (PHD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:J
Last Name:LARRABEE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 BAHIA VISTA ST
Mailing Address - Street 2:SUITE 308
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-2635
Mailing Address - Country:US
Mailing Address - Phone:941-955-9596
Mailing Address - Fax:941-957-3485
Practice Address - Street 1:2650 BAHIA VISTA ST
Practice Address - Street 2:SUITE 308
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2635
Practice Address - Country:US
Practice Address - Phone:941-955-9596
Practice Address - Fax:941-957-3485
Is Sole Proprietor?:No
Enumeration Date:2008-02-29
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3543103G00000X, 103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75898Medicare UPIN