Healthcare Provider Details

I. General information

NPI: 1053812461
Provider Name (Legal Business Name): KALEB ORVILLE LARSON MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MARTY ORVILLE LARSON MS

II. Dates (important events)

Enumeration Date: 02/22/2018
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 S. US HWY 41
TERRE HAUTE IN
47805-4749
US

IV. Provider business mailing address

GIBAULT CARE INC. 6401 S. US HWY 41
TERRE HAUTE IN
47805-4749
US

V. Phone/Fax

Practice location:
  • Phone: 812-299-1156
  • Fax: 812-299-0118
Mailing address:
  • Phone: 812-299-1156
  • Fax: 812-299-0118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39004107A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: