Healthcare Provider Details

I. General information

NPI: 1659406791
Provider Name (Legal Business Name): PATRICIA BYRNE LARSON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 NEEDHAM ST
NEWTON MA
02464-1596
US

IV. Provider business mailing address

33 PRINCESS RD
NEWTON MA
02465-1636
US

V. Phone/Fax

Practice location:
  • Phone: 161-752-7461
  • Fax:
Mailing address:
  • Phone: 161-733-2587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4196
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierP10309
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBCBS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: