Provider Demographics
NPI:1750520524
Name:LARSEN, GORDON LEE (PH D)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:LEE
Last Name:LARSEN
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 N MAYFAIR ROAD
Mailing Address - Street 2:SUITE 785
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1327
Mailing Address - Country:US
Mailing Address - Phone:414-258-5704
Mailing Address - Fax:414-258-8406
Practice Address - Street 1:2600 N MAYFAIR RD STE 785
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-1327
Practice Address - Country:US
Practice Address - Phone:414-258-5704
Practice Address - Fax:414-258-8406
Is Sole Proprietor?:No
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist