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General NPI Number Information
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NPI Number | 1609396183
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Entity Type | Organization
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Legal Business Name | KENNETH L. LARSON, PH.D., INC.
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Dates
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Enumeration Date | 06/26/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1891 E ROSEVILLE PKWY STE 100
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City | ROSEVILLE
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State | CA
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Zip | 95661-7974
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Country | US
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Telephone | 916-789-7082
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Fax | 916-797-8840
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Provider Business Mailing Address
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Address Line | 1891 E ROSEVILLE PKWY STE 100
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City | ROSEVILLE
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State | CA
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Zip | 95661-7974
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Country | US
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Telephone | 916-789-7082
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Fax | 916-797-8840
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | DR. KENNETH LEROY LARSON
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Credential | PH.D.
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Telephone | 916-717-9368
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY16221
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License Number State | CA
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