Provider Demographics
NPI:1548292972
Name:LARSEN, GARY YOUNG (PHD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:YOUNG
Last Name:LARSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-4242
Mailing Address - Country:US
Mailing Address - Phone:712-323-1728
Mailing Address - Fax:712-323-8888
Practice Address - Street 1:601 WILLOW AVE
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-4242
Practice Address - Country:US
Practice Address - Phone:712-323-1728
Practice Address - Fax:712-323-8888
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA116103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0100495Medicaid
IARO3183Medicare UPIN
IA0100495Medicaid