Healthcare Provider Details

I. General information

NPI: 1407553548
Provider Name (Legal Business Name): ELIZABETH LARSEN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2023
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 E BROADWAY AVE
BISMARCK ND
58501-5085
US

IV. Provider business mailing address

217 W BURLEIGH AVE APT 214
BISMARCK ND
58504-9049
US

V. Phone/Fax

Practice location:
  • Phone: 701-751-0299
  • Fax:
Mailing address:
  • Phone: 406-565-0993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6371
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: