Provider Demographics
NPI:1942085279
Name:LARSON, ERIC GREGORY
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:GREGORY
Last Name:LARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2552
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92859-0552
Mailing Address - Country:US
Mailing Address - Phone:323-459-2369
Mailing Address - Fax:
Practice Address - Street 1:12966 EUCLID ST STE 280
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-9202
Practice Address - Country:US
Practice Address - Phone:714-823-4770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA142315106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist