MEDICARE: KAYLIE A LARSEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811596885
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYLIE A LARSEN

Provider Business Mailing Address
First Line	:	230 W 200 S # 142
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84101-1337
Country	:	US
Telephone Number	:	801-433-2595
Fax Number	:

Provider Business Practice Location Address
First Line	:	230 W 200 S # 142
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84101-1337
Country	:	US
Telephone Number	:	801-433-2595
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2020
Last Update Date	:	10/21/2020

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Directions to “ KAYLIE A LARSEN ” Practice Location

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