Provider Demographics
NPI:1871889261
Name:PETTICORD, LARSTON (MS, LPC)
Entity type:Individual
Prefix:MR
First Name:LARSTON
Middle Name:
Last Name:PETTICORD
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11626 NE EVERETT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-2362
Mailing Address - Country:US
Mailing Address - Phone:503-914-6199
Mailing Address - Fax:
Practice Address - Street 1:3419 NE SANDY BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1959
Practice Address - Country:US
Practice Address - Phone:503-914-6199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health