Provider Demographics
NPI:1649328493
Name:LARSON, ESSIE M (PHD)
Entity type:Individual
Prefix:DR
First Name:ESSIE
Middle Name:M
Last Name:LARSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 CEDAR LN
Mailing Address - Street 2:SUITE #8
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4315
Mailing Address - Country:US
Mailing Address - Phone:201-888-7135
Mailing Address - Fax:
Practice Address - Street 1:175 CEDAR LN
Practice Address - Street 2:SUITE #8
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4315
Practice Address - Country:US
Practice Address - Phone:201-888-7135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016952103TC0700X
NJ35SI00453900103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical