Provider Demographics
NPI:1366141335
Name:LARSON, JOHN PAUL (SUDPT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:PAUL
Last Name:LARSON
Suffix:
Gender:M
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 HARVEY RD NE STE C
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-4294
Mailing Address - Country:US
Mailing Address - Phone:253-939-2211
Mailing Address - Fax:253-939-2867
Practice Address - Street 1:921 HARVEY RD NE STE C
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-4294
Practice Address - Country:US
Practice Address - Phone:253-939-2211
Practice Address - Fax:253-939-2867
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61355679101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)