Healthcare Provider Details

I. General information

NPI: 1124088208
Provider Name (Legal Business Name): MARK R. LARSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 ALLENS CREEK RD
ROCHESTER NY
14618-3305
US

IV. Provider business mailing address

130 ALLENS CREEK RD
ROCHESTER NY
14618-3305
US

V. Phone/Fax

Practice location:
  • Phone: 585-473-5810
  • Fax: 585-473-5193
Mailing address:
  • Phone: 585-473-5810
  • Fax: 585-473-5193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number013650
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: