MEDICARE: DR. PAUL C. LARSON PH.D.

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	103T00000X	Psychologist	071003617	IL

General Provider Information

NPI Number	:	1679604771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAUL C. LARSON PH.D.

Provider Business Mailing Address
First Line	:	222 MERCHANDISE MART PLAZA
Second Line	:	SUITE #13-659
City	:	CHICAGO
State	:	IL
Zip	:	60654-4705
Country	:	US
Telephone Number	:	312-467-0150
Fax Number	:	312-467-0150

Provider Business Practice Location Address
First Line	:	222 MERCHANDISE MART PLZ
Second Line	:	SUITE #13-659
City	:	CHICAGO
State	:	IL
Zip	:	60654-1103
Country	:	US
Telephone Number	:	312-467-0150
Fax Number	:	312-467-0150

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

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	02/03/2010

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