Provider Demographics
NPI:1053933705
Name:LARSON, EMMA GRACE (PHD)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:GRACE
Last Name:LARSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 SARGENT RD NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2841
Mailing Address - Country:US
Mailing Address - Phone:202-650-6361
Mailing Address - Fax:202-250-6362
Practice Address - Street 1:4801 SARGENT RD NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2841
Practice Address - Country:US
Practice Address - Phone:202-650-6361
Practice Address - Fax:202-250-6362
Is Sole Proprietor?:No
Enumeration Date:2020-05-15
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06938103T00000X
DCPSY200001381103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47037660624Medicaid
NE47037660631Medicaid