Healthcare Provider Details

I. General information

NPI: 1740497643
Provider Name (Legal Business Name): GLENN J LARRABEE PH D PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 02/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 BAHIA VISTA ST SUITE 308
SARASOTA FL
34239-2635
US

IV. Provider business mailing address

2650 BAHIA VISTA ST SUITE 308
SARASOTA FL
34239-2635
US

V. Phone/Fax

Practice location:
  • Phone: 941-955-9596
  • Fax: 941-957-3485
Mailing address:
  • Phone: 941-955-9596
  • Fax: 941-957-3485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY 3543
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY3543
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPY 3543
License Number StateFL

VIII. Authorized Official

Name: DR. GLENN JOSEPH LARRABEE
Title or Position: OWNER
Credential:
Phone: 941-955-9596