Provider Demographics
NPI:1265543995
Name:LARSEN, JOHN A (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:LARSEN
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 1:5350 W 94TH TER
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66207-2504
Mailing Address - Country:US
Mailing Address - Phone:913-322-4235
Mailing Address - Fax:913-322-4236
Practice Address - Street 1:5350 W 94TH TER
Practice Address - Street 2:SUITE 204
Practice Address - City:PRAIRIE VILLAGE
Practice Address - State:KS
Practice Address - Zip Code:66207-2504
Practice Address - Country:US
Practice Address - Phone:913-322-4235
Practice Address - Fax:913-322-4236
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1300103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493440309Medicaid
MO09792026OtherBCBS
MO1040001Medicare PIN