Provider Demographics
NPI:1811179633
Name:MCGILL, LARRY EDWARD
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:EDWARD
Last Name:MCGILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16500 PIERCE FERRY RD
Mailing Address - Street 2:
Mailing Address - City:DOLAN SPRINGS
Mailing Address - State:AZ
Mailing Address - Zip Code:86441
Mailing Address - Country:US
Mailing Address - Phone:928-767-3350
Mailing Address - Fax:928-767-4330
Practice Address - Street 1:16500 PIERCE FERRY RD
Practice Address - Street 2:
Practice Address - City:DOLAN SPRINGS
Practice Address - State:AZ
Practice Address - Zip Code:86441
Practice Address - Country:US
Practice Address - Phone:928-767-3350
Practice Address - Fax:928-767-4330
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool