Healthcare Provider Details

I. General information

NPI: 1598311458
Provider Name (Legal Business Name): JAMIE LARSON MED, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 02/01/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12300 PERRY HWY
WEXFORD PA
15090-8379
US

IV. Provider business mailing address

142 OVERBROOK RD
VALENCIA PA
16059-1108
US

V. Phone/Fax

Practice location:
  • Phone: 724-933-4673
  • Fax:
Mailing address:
  • Phone: 724-766-9181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-17-44761
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: