Healthcare Provider Details

I. General information

NPI: 1942040472
Provider Name (Legal Business Name): THERESA A LARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2024
Last Update Date: 05/31/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 LAKE COOK RD STE 2
DEERFIELD IL
60015-5263
US

IV. Provider business mailing address

440 LAKE COOK RD STE 2
DEERFIELD IL
60015-5263
US

V. Phone/Fax

Practice location:
  • Phone: 847-236-9310
  • Fax: 847-236-9411
Mailing address:
  • Phone: 847-236-9310
  • Fax: 847-236-9411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.029761
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: