Healthcare Provider Details

I. General information

NPI: 1376906503
Provider Name (Legal Business Name): CAMERON LARSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7530 E ANGUS DR
SCOTTSDALE AZ
85251-6410
US

IV. Provider business mailing address

7530 E ANGUS DR
SCOTTSDALE AZ
85251-6410
US

V. Phone/Fax

Practice location:
  • Phone: 480-947-5739
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-15885
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: