Provider Demographics
NPI:1881927291
Name:LARSEN, PAUL A (MFT)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:A
Last Name:LARSEN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17662 IRVINE BLVD STE 11
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3133
Mailing Address - Country:US
Mailing Address - Phone:714-865-9269
Mailing Address - Fax:
Practice Address - Street 1:17662 IRVINE BLVD STE 11
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3133
Practice Address - Country:US
Practice Address - Phone:714-865-9269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC38005106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist