Provider Demographics
NPI:1851123061
Name:LARSON, STEVEN KENNETH (SLP)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:KENNETH
Last Name:LARSON
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16690 SW MATADOR LN APT SUITE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97224-2150
Mailing Address - Country:US
Mailing Address - Phone:602-517-7017
Mailing Address - Fax:
Practice Address - Street 1:1309 NE 27TH ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-2399
Practice Address - Country:US
Practice Address - Phone:503-472-4678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17126235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist