Provider Demographics
NPI:1679604771
Name:LARSON, PAUL C (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:C
Last Name:LARSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:222 MERCHANDISE MART PLAZA
Mailing Address - Street 2:SUITE #13-659
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-4705
Mailing Address - Country:US
Mailing Address - Phone:312-467-0150
Mailing Address - Fax:312-467-0150
Practice Address - Street 1:222 MERCHANDISE MART PLZ
Practice Address - Street 2:SUITE #13-659
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-1103
Practice Address - Country:US
Practice Address - Phone:312-467-0150
Practice Address - Fax:312-467-0150
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071003617103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist