Provider Demographics
NPI:1174767354
Name:DANIELS, LARRY KENNETH (MA)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:KENNETH
Last Name:DANIELS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 91294
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36691-1294
Mailing Address - Country:US
Mailing Address - Phone:251-639-1022
Mailing Address - Fax:251-639-1160
Practice Address - Street 1:6512 GRELOT RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-2657
Practice Address - Country:US
Practice Address - Phone:251-639-1022
Practice Address - Fax:251-639-1160
Is Sole Proprietor?:No
Enumeration Date:2009-05-01
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC1450A101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional