Provider Demographics
NPI:1689021222
Name:LARSON, TESSALA KEI (BA)
Entity Type:Individual
Prefix:
First Name:TESSALA
Middle Name:KEI
Last Name:LARSON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 W 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-3758
Mailing Address - Country:US
Mailing Address - Phone:510-371-2878
Mailing Address - Fax:
Practice Address - Street 1:550 RIVER RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-3212
Practice Address - Country:US
Practice Address - Phone:510-371-2878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor