Healthcare Provider Details

I. General information

NPI: 1801194840
Provider Name (Legal Business Name): SCOTT WESLEY LARSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2011
Last Update Date: 02/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 DOVE ST STE 240
NEWPORT BEACH CA
92660-2806
US

IV. Provider business mailing address

1151 DOVE ST STE 240
NEWPORT BEACH CA
92660-2806
US

V. Phone/Fax

Practice location:
  • Phone: 949-689-6047
  • Fax: 949-223-4296
Mailing address:
  • Phone: 949-689-6047
  • Fax: 949-223-4296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY19684
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: