Provider Demographics
NPI:1194572487
Name:LARSON, NARUDET
Entity type:Individual
Prefix:
First Name:NARUDET
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 GATEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-3132
Mailing Address - Country:US
Mailing Address - Phone:331-269-8444
Mailing Address - Fax:
Practice Address - Street 1:3530 GATEWOOD LN
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-3132
Practice Address - Country:US
Practice Address - Phone:331-269-8444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-03
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-24-345077106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician