Basic Information
| Provider Information | |||||||||
| NPI: | 1124091749 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | PAUL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 721 AMERICAN AVENUE SUITE 501 | ||||||||
| Address2: | PHC BEHAVIORAL MEDICINE CENTER | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629282396 | ||||||||
| FaxNumber: | 2625441213 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 AMERICAN AVENUE SUITE 501 | ||||||||
| Address2: | PHC BEHAVIORAL MEDICINE CENTER | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629282396 | ||||||||
| FaxNumber: | 2625441213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 04/25/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | 39093 | WI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 34096900 | 05 | WI | MEDICAID |