Provider Demographics
NPI:1407671134
Name:LARSEN, PAYTON (ALMFT)
Entity type:Individual
Prefix:
First Name:PAYTON
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:ALMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 W CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-5236
Mailing Address - Country:US
Mailing Address - Phone:312-339-8604
Mailing Address - Fax:
Practice Address - Street 1:1502 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-5236
Practice Address - Country:US
Practice Address - Phone:312-339-8604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208001251106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist