MEDICARE: MRS. LORI LYNN LARSON MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFT36109	CA

General Provider Information

NPI Number	:	1063637940
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LORI LYNN LARSON MFT

Provider Business Mailing Address
First Line	:	PO BOX 1655
Second Line	:
City	:	GEORGETOWN
State	:	CA
Zip	:	95634-1655
Country	:	US
Telephone Number	:	530-417-5308
Fax Number	:

Provider Business Practice Location Address
First Line	:	6692 MERCHANDISE WAY
Second Line	:	STE. B
City	:	DIAMOND SPRINGS
State	:	CA
Zip	:	95619-9453
Country	:	US
Telephone Number	:	530-626-2589
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	07/08/2007

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