MEDICARE: TONYA B LARSON LISW

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	1041C0700X	Clinical Social Worker	00645	IA

General Provider Information

NPI Number	:	1922270388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TONYA B LARSON LISW

Provider Business Mailing Address
First Line	:	409 KENYON RD
Second Line	:	SUITE C
City	:	FORT DODGE
State	:	IA
Zip	:	50501-5718
Country	:	US
Telephone Number	:	515-573-3138
Fax Number	:	515-573-3130

Provider Business Practice Location Address
First Line	:	409 KENYON RD
Second Line	:	SUITE C
City	:	FORT DODGE
State	:	IA
Zip	:	50501-5718
Country	:	US
Telephone Number	:	515-573-3138
Fax Number	:	515-573-3130

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

Provider Enumeration Date	:	03/26/2008
Last Update Date	:	04/09/2014

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