Healthcare Provider Details

I. General information

NPI: 1134985542
Provider Name (Legal Business Name): BENJAMIN K LARSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2024
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8577 E MARKET ST
WARREN OH
44484-2345
US

IV. Provider business mailing address

2980 BELMONT AVE
YOUNGSTOWN OH
44505-1834
US

V. Phone/Fax

Practice location:
  • Phone: 330-856-6663
  • Fax: 330-856-1581
Mailing address:
  • Phone: 330-759-0276
  • Fax: 330-759-0030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.2405604-TRNE
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.2406657
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: