Provider Demographics
NPI:1427257492
Name:LARCOM, MELISSA JEAN (MA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:JEAN
Last Name:LARCOM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 ELDORADO BLVD
Mailing Address - Street 2:1236
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021-8809
Mailing Address - Country:US
Mailing Address - Phone:720-302-3383
Mailing Address - Fax:
Practice Address - Street 1:10190 BANNOCK ST
Practice Address - Street 2:SUITE 110
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80260-6083
Practice Address - Country:US
Practice Address - Phone:720-302-3383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
COLPC4127101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health