Healthcare Provider Details

I. General information

NPI: 1215408422
Provider Name (Legal Business Name): STEPHANIE LARSON BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 MUNICIPAL DR
ARNOLD MO
63010-1012
US

IV. Provider business mailing address

227 MAIN ST
FESTUS MO
63028-1952
US

V. Phone/Fax

Practice location:
  • Phone: 636-296-6206
  • Fax:
Mailing address:
  • Phone: 636-931-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2023017692
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: