Provider Demographics
NPI:1891806675
Name:LARSON, KENNETH L (PHD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:LARSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4580 KLAHANIE DR SE
Mailing Address - Street 2:PMB 445
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98029-5812
Mailing Address - Country:US
Mailing Address - Phone:425-278-9351
Mailing Address - Fax:425-209-0968
Practice Address - Street 1:1891 E ROSEVILLE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-7974
Practice Address - Country:US
Practice Address - Phone:916-789-7082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY61229677103TC0700X
CAPSY16221103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical