=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114100278
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN P LARSON LPCC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2007
-----------------------------------------------------
Last Update Date | 08/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2703 FRONTIER ST NE SUITE 120 MSC11 6145
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-552-9321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4211 HANNETT AVE NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87110-4941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-553-5844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0135901
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------