Basic Information
| Provider Information | |||||||||
| NPI: | 1295062883 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | SHERRI | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 N CLARK ST | ||||||||
| Address2: | SUITE 2650 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606024109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662965260 | ||||||||
| FaxNumber: | 3125581570 | ||||||||
| Practice Location | |||||||||
| Address1: | 19740 GOVERNORS HWY | ||||||||
| Address2: | SUITE 117 | ||||||||
| City: | FLOSSMOOR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604222084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662965262 | ||||||||
| FaxNumber: | 7089579588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2009 | ||||||||
| LastUpdateDate: | 11/03/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 180004355 | IL | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 180004355 | 01 | IL | STATE OF ILLINOIS | OTHER |