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General NPI Number Information
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NPI Number | 1679604771
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Entity Type | Individual
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Provider Name | PAUL C. LARSON PH.D.
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Gender | Male
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Dates
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Enumeration Date | 03/08/2007
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Last Update Date | 02/03/2010
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Provider Practice Location Address
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Address Line | 222 MERCHANDISE MART PLZ SUITE #13-659
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City | CHICAGO
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State | IL
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Zip | 60654-1103
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Country | US
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Telephone | 312-467-0150
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Fax | 312-467-0150
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Provider Business Mailing Address
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Address Line | 222 MERCHANDISE MART PLAZA SUITE #13-659
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City | CHICAGO
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State | IL
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Zip | 60654-4705
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Country | US
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Telephone | 312-467-0150
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Fax | 312-467-0150
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 071003617
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License Number State | IL
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