Healthcare Provider Details

I. General information

NPI: 1972914505
Provider Name (Legal Business Name): KURT LAROSE MSW LCSW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2014
Last Update Date: 02/24/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E HARVEST CIR
PERRYVILLE MO
63775-9330
US

IV. Provider business mailing address

1701 E HARVEST CIR
PERRYVILLE MO
63775-9330
US

V. Phone/Fax

Practice location:
  • Phone: 850-545-2886
  • Fax:
Mailing address:
  • Phone: 850-545-2886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW9297
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberLC50081569
License Number StateDC

VIII. Authorized Official

Name: MR. KURT DOMINICK LAROSE
Title or Position: SOLE PROPRIETOR
Credential: LCSW LICSW
Phone: 850-545-2886