Basic Information
| Provider Information | |||||||||
| NPI: | 1891806675 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4580 KLAHANIE DR SE | ||||||||
| Address2: | PMB 445 | ||||||||
| City: | SAMMAMISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980295812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252789351 | ||||||||
| FaxNumber: | 4252090968 | ||||||||
| Practice Location | |||||||||
| Address1: | 1891 E ROSEVILLE PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956617974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167897082 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 09/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PY61229677 | WA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | PSY16221 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.