Provider Demographics
NPI:1336262245
Name:LARSEN, TERESA GAIL (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:GAIL
Last Name:LARSEN
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 114TH AVENUE SE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-6928
Mailing Address - Country:US
Mailing Address - Phone:425-260-6071
Mailing Address - Fax:
Practice Address - Street 1:1300 114TH AVENUE SE
Practice Address - Street 2:SUITE 108
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-6928
Practice Address - Country:US
Practice Address - Phone:425-260-6071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00005034101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health