Provider Demographics
NPI:1194804336
Name:LARSON, LESLIE ANN (PHD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:LARSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 ARDEN AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-4006
Mailing Address - Country:US
Mailing Address - Phone:818-569-5416
Mailing Address - Fax:818-241-6853
Practice Address - Street 1:410 ARDEN AVE STE 201
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-4006
Practice Address - Country:US
Practice Address - Phone:818-569-5416
Practice Address - Fax:818-241-6853
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16503103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical