Provider Demographics
NPI:1649230160
Name:LARSON, STEPHEN (PSY D)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:352 HOMMELVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SAUGERTIES
Mailing Address - State:NY
Mailing Address - Zip Code:12477-4205
Mailing Address - Country:US
Mailing Address - Phone:951-285-3306
Mailing Address - Fax:
Practice Address - Street 1:352 HOMMELVILLE RD
Practice Address - Street 2:
Practice Address - City:SAUGERTIES
Practice Address - State:NY
Practice Address - Zip Code:12477-4205
Practice Address - Country:US
Practice Address - Phone:951-285-3306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018768-1103TC0700X
METP1267103TC0700X
NC2584103TC2200X
MEPS1267103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME433395199Medicaid
NC6002550Medicaid
ME001375401Medicare PIN