Provider Demographics
NPI:1710065016
Name:LARSEN, MARY V (EDD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:V
Last Name:LARSEN
Suffix:
Gender:F
Credentials:EDD
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 1595
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-8095
Mailing Address - Country:US
Mailing Address - Phone:860-788-6404
Mailing Address - Fax:
Practice Address - Street 1:100 CHARLES EWING BLVD
Practice Address - Street 2:
Practice Address - City:EWING
Practice Address - State:NJ
Practice Address - Zip Code:08628-3454
Practice Address - Country:US
Practice Address - Phone:860-788-6404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00319100103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P25894Medicare UPIN