Healthcare Provider Details

I. General information

NPI: 1144885856
Provider Name (Legal Business Name): KRISTY LARSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date: 06/06/2022
Reactivation Date: 07/08/2022

III. Provider practice location address

701 MACY DR
ROSWELL GA
30076-6332
US

IV. Provider business mailing address

701 MACY DR
ROSWELL GA
30076-6332
US

V. Phone/Fax

Practice location:
  • Phone: 678-538-9823
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY004765
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: