Provider Demographics
NPI:1588162473
Name:LARRIEU, DUSTIN TYLER
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:TYLER
Last Name:LARRIEU
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 1:21600 OXNARD ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-4976
Mailing Address - Country:US
Mailing Address - Phone:818-345-2345
Mailing Address - Fax:
Practice Address - Street 1:2437 GRAND AVE STE BCD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-6620
Practice Address - Country:US
Practice Address - Phone:805-941-3656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00003058106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician