Provider Demographics
NPI:1841634425
Name:LARSEN, STEPHEN VINCENT (QMHP, MS)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:VINCENT
Last Name:LARSEN
Suffix:
Gender:M
Credentials:QMHP, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 SW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-5037
Mailing Address - Country:US
Mailing Address - Phone:503-886-9475
Mailing Address - Fax:
Practice Address - Street 1:36 SW NYE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-3821
Practice Address - Country:US
Practice Address - Phone:541-265-4179
Practice Address - Fax:541-265-4194
Is Sole Proprietor?:No
Enumeration Date:2013-04-25
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health