Provider Demographics
NPI:1659658748
Name:SARGENT, LARRY CHARLES (MA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:CHARLES
Last Name:SARGENT
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:LARRY
Other - Middle Name:
Other - Last Name:SARGENT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:167 PALENCIA VILLAGE DRIVE SUITE 101
Mailing Address - Street 2:
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095
Mailing Address - Country:US
Mailing Address - Phone:904-224-5108
Mailing Address - Fax:
Practice Address - Street 1:167 PALENCIA VILLAGE DR STE 101
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-8450
Practice Address - Country:US
Practice Address - Phone:904-224-5108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT 1254106H00000X
FLIMH 7278101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist