Provider Demographics
NPI:1750408498
Name:LARSEN, SUE (MA, MFT)
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:738 LUSCOMBE STREET
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97351
Mailing Address - Country:US
Mailing Address - Phone:503-838-2101
Mailing Address - Fax:
Practice Address - Street 1:182 SW ACADEMY ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1922
Practice Address - Country:US
Practice Address - Phone:503-623-9289
Practice Address - Fax:503-831-1726
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health