Provider Demographics
NPI:1831895937
Name:LARSON, SASHA NICOLE
Entity type:Individual
Prefix:
First Name:SASHA
Middle Name:NICOLE
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 SW 35TH PL UNIT O-86
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-3252
Mailing Address - Country:US
Mailing Address - Phone:850-420-1644
Mailing Address - Fax:
Practice Address - Street 1:2720 NW 6TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-2994
Practice Address - Country:US
Practice Address - Phone:352-649-3876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-01
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH21851101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH21851OtherLICENSED MENTAL HEALTH COUNSELOR