Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | PSY31449 | CA |
N | 103T00000X | Psychologist | PSY31449 | CA |
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | PSY31449 | CA |
N | 103TB0200X | Cognitive & Behavioral Psychologist | PSY31449 | CA |
Y | 103G00000X | Clinical Psychologist | PSY31449 | CA |
Y | 103TC0700X | Clinical Psychologist | PSY31449 | CA |
N | 103TH0004X | Health Psychologist | PSY31449 | CA |
NPI | 1063046225 |
---|---|
Provider Name | Dr. Larry Edwin Burrell II |
First Address | Martinez, CA 94553-4668 |
Second Address | Martinez, CA 94553-4668 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/02/2020 |
Last Update Date | 26/02/2020 |