Provider Demographics
NPI:1194876516
Name:BURSON, LARRY ELDON (LPC)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:ELDON
Last Name:BURSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 W MAIN ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-3740
Mailing Address - Country:US
Mailing Address - Phone:830-997-4662
Mailing Address - Fax:830-990-8102
Practice Address - Street 1:307 W MAIN ST
Practice Address - Street 2:SUITE 204
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-3740
Practice Address - Country:US
Practice Address - Phone:830-997-4662
Practice Address - Fax:830-990-8102
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12876101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional