Provider Demographics
NPI:1144885856
Name:LARSEN, KRISTY
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:LARSEN
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 1:701 MACY DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-6332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 MACY DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-6332
Practice Address - Country:US
Practice Address - Phone:678-538-9823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2025-04-22
Deactivation Date:2022-06-06
Deactivation Code:
Reactivation Date:2022-07-08
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 103TC2200X
GAPSY004765103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician