Provider Demographics
NPI:1881794535
Name:LARSON, THERESA M (LPC)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:LARSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6310 N LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:HOUSE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:63051-1122
Mailing Address - Country:US
Mailing Address - Phone:314-805-4261
Mailing Address - Fax:314-849-0159
Practice Address - Street 1:10004 KENNERLY RD
Practice Address - Street 2:SUITE 362B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2141
Practice Address - Country:US
Practice Address - Phone:314-849-0450
Practice Address - Fax:314-849-0159
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002139101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498662501Medicaid