Basic Information
| Provider Information | |||||||||
| NPI: | 1609396183 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENNETH L. LARSON, PH.D., INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1891 E ROSEVILLE PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956617974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167897082 | ||||||||
| FaxNumber: | 9167978840 | ||||||||
| Practice Location | |||||||||
| Address1: | 1891 E ROSEVILLE PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956617974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167897082 | ||||||||
| FaxNumber: | 9167978840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | LARSON | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | LEROY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 9167179368 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY16221 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | PSY16221 | 01 | CA | CALIFORNIA BOARD OF PSYCHOLOGY | OTHER |