Provider Demographics
NPI:1356695084
Name:LARSON, LYNN DALE (PHD)
Entity type:Individual
Prefix:DR
First Name:LYNN
Middle Name:DALE
Last Name:LARSON
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 1:2980 S RAINBOW BLVD
Mailing Address - Street 2:SUITE 200A
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-6531
Mailing Address - Country:US
Mailing Address - Phone:702-315-5670
Mailing Address - Fax:702-315-5672
Practice Address - Street 1:2980 S RAINBOW BLVD
Practice Address - Street 2:SUITE 200A
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-6531
Practice Address - Country:US
Practice Address - Phone:702-315-5670
Practice Address - Fax:702-315-5672
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-02
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPY137103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1911456000OtherOWCP DOL