Healthcare Provider Details

I. General information

NPI: 1225456106
Provider Name (Legal Business Name): SHYLENE LARSON MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2014
Last Update Date: 03/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S MAIN ST
LEBANON OR
97355-3109
US

IV. Provider business mailing address

1600 S MAIN ST
LEBANON OR
97355-3109
US

V. Phone/Fax

Practice location:
  • Phone: 541-451-5932
  • Fax:
Mailing address:
  • Phone: 541-451-5932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: