Healthcare Provider Details

I. General information

NPI: 1326003344
Provider Name (Legal Business Name): ERIC JOHN LARSON EL CADC BS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 E EUREKA
EUREKA IL
61530
US

IV. Provider business mailing address

109 E EUREKA
EUREKA IL
61530
US

V. Phone/Fax

Practice location:
  • Phone: 309-467-3770
  • Fax: 309-467-5356
Mailing address:
  • Phone: 309-467-3770
  • Fax: 309-467-5356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number14471
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: