Healthcare Provider Details

I. General information

NPI: 1487188611
Provider Name (Legal Business Name): LARRY WASSON III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2017
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 22ND ST
SACRAMENTO CA
95816-4907
US

IV. Provider business mailing address

2358 MARITIME DR STE 110
ELK GROVE CA
95758-3662
US

V. Phone/Fax

Practice location:
  • Phone: 305-933-8172
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number34925
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: