Provider Demographics
NPI:1942040472
Name:LARSON, THERESA A
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 LAKE COOK RD STE 2
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-5263
Mailing Address - Country:US
Mailing Address - Phone:847-236-9310
Mailing Address - Fax:847-236-9411
Practice Address - Street 1:440 LAKE COOK RD STE 2
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-5263
Practice Address - Country:US
Practice Address - Phone:847-236-9310
Practice Address - Fax:847-236-9411
Is Sole Proprietor?:No
Enumeration Date:2024-05-31
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.029761363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health