Provider Demographics
NPI:1629292859
Name:LARUSSA, THOMAS KEITH (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:KEITH
Last Name:LARUSSA
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 1:101 N ELM ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-4105
Mailing Address - Country:US
Mailing Address - Phone:940-566-4691
Mailing Address - Fax:940-566-5366
Practice Address - Street 1:101 N ELM ST
Practice Address - Street 2:SUITE 203
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-4105
Practice Address - Country:US
Practice Address - Phone:940-566-4691
Practice Address - Fax:940-566-5366
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9262101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional