Healthcare Provider Details

I. General information

NPI: 1457685786
Provider Name (Legal Business Name): LARRY JUAN PARKER JR. M.ED.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2009
Last Update Date: 02/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 ST THOMAS RD
FAYETTEVILLE NC
28311-2999
US

IV. Provider business mailing address

220 ST THOMAS RD
FAYETTEVILLE NC
28311-2999
US

V. Phone/Fax

Practice location:
  • Phone: 910-978-4128
  • Fax:
Mailing address:
  • Phone: 910-978-4128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number98 00005
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: