Provider Demographics
NPI:1134985542
Name:LARSON, BENJAMIN K
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:K
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 1:2980 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-1834
Mailing Address - Country:US
Mailing Address - Phone:330-759-0276
Mailing Address - Fax:330-759-0030
Practice Address - Street 1:8577 E MARKET ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-2345
Practice Address - Country:US
Practice Address - Phone:330-856-6663
Practice Address - Fax:330-856-1581
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-23
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2405604-TRNE101YP2500X
OHC.2406657101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional