Provider Demographics
NPI:1861981730
Name:LARSON, SAMANTHA GAIL
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:GAIL
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 1:11719 GALLANT FOX RD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-2591
Mailing Address - Country:US
Mailing Address - Phone:505-604-1099
Mailing Address - Fax:
Practice Address - Street 1:11719 GALLANT FOX RD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87123-2591
Practice Address - Country:US
Practice Address - Phone:505-604-1099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health