Healthcare Provider Details

I. General information

NPI: 1336100932
Provider Name (Legal Business Name): MOLLY G LARSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2829 4TH AVE STE 150
LAKE CHARLES LA
70601-7897
US

IV. Provider business mailing address

PO BOX 123977 DEPT 3977
DALLAS TX
75312-3977
US

V. Phone/Fax

Practice location:
  • Phone: 337-480-7800
  • Fax: 337-474-4552
Mailing address:
  • Phone: 337-494-2921
  • Fax: 373-494-6523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2394
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number71
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: