Provider Demographics
NPI:1245926591
Name:LARSON, ELAINE NAOMI
Entity type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:NAOMI
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-2492
Mailing Address - Country:US
Mailing Address - Phone:847-570-5020
Mailing Address - Fax:
Practice Address - Street 1:2530 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-2492
Practice Address - Country:US
Practice Address - Phone:847-570-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician