Basic Information
| Provider Information | |||||||||
| NPI: | 1841634425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | VINCENT | ||||||||
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| Credential: | QMHP, MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 SW 6TH ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973655037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038869475 | ||||||||
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| Practice Location | |||||||||
| Address1: | 36 SW NYE ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973653821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412654179 | ||||||||
| FaxNumber: | 5412654194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2013 | ||||||||
| LastUpdateDate: | 01/19/2017 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.