Provider Demographics
NPI:1689630675
Name:LARSON, TRACY LORRAINE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LORRAINE
Last Name:LARSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-1336
Mailing Address - Country:US
Mailing Address - Phone:315-331-6030
Mailing Address - Fax:315-331-9119
Practice Address - Street 1:211 WEST AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1336
Practice Address - Country:US
Practice Address - Phone:315-331-6030
Practice Address - Fax:315-331-9119
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014099103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist