Healthcare Provider Details

I. General information

NPI: 1114100278
Provider Name (Legal Business Name): JOHN P LARSON LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2007
Last Update Date: 08/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2703 FRONTIER ST NE SUITE 120 MSC11 6145
ALBUQUERQUE NM
87131
US

IV. Provider business mailing address

4211 HANNETT AVE NE
ALBUQUERQUE NM
87110-4941
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-9321
  • Fax:
Mailing address:
  • Phone: 505-553-5844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0135901
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: