Provider Demographics
NPI:1336538479
Name:LARSEN, DEREK (MS, NCC)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:LARSEN
Suffix:
Gender:M
Credentials:MS, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 FELSPAR ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-2836
Mailing Address - Country:US
Mailing Address - Phone:315-727-0841
Mailing Address - Fax:
Practice Address - Street 1:734 10TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-6502
Practice Address - Country:US
Practice Address - Phone:619-239-4663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health