Provider Demographics
NPI:1922570100
Name:LARSON, JUSTIN LARS (CDCA, CPRS)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LARS
Last Name:LARSON
Suffix:
Gender:M
Credentials:CDCA, CPRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:OH
Mailing Address - Zip Code:44420-3244
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:412 OHIO AVE
Practice Address - Street 2:
Practice Address - City:GIRARD
Practice Address - State:OH
Practice Address - Zip Code:44420-3244
Practice Address - Country:US
Practice Address - Phone:330-314-6647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-27
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH00566175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist