Provider Demographics
NPI:1124088208
Name:LARSON, MARK R (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:LARSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 ALLENS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-3305
Mailing Address - Country:US
Mailing Address - Phone:585-473-5810
Mailing Address - Fax:585-473-5193
Practice Address - Street 1:130 ALLENS CREEK RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-3305
Practice Address - Country:US
Practice Address - Phone:585-473-5810
Practice Address - Fax:585-473-5193
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013650103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY106063FCOtherPREFERRED CARE
NY7043329OtherAETNA
NYS13650-7WOtherWORKER'S COMPENSATION
NYP06239Medicare UPIN
NYDD5458Medicare ID - Type Unspecified