Provider Demographics
NPI:1801011580
Name:LARSON, DOUGLAS WAYNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:WAYNE
Last Name:LARSON
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 1:11454 GOLDEN GATE DR
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-9705
Mailing Address - Country:US
Mailing Address - Phone:909-798-8999
Mailing Address - Fax:
Practice Address - Street 1:1430 E COOLEY DR
Practice Address - Street 2:SUITE 209
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3934
Practice Address - Country:US
Practice Address - Phone:909-798-8999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9281103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical