Healthcare Provider Details

I. General information

NPI: 1841664380
Provider Name (Legal Business Name): ELISE ANN LARSEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2015
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 E ROOSEVELT AVE
GRANTS NM
87020-2118
US

IV. Provider business mailing address

1016 E ROOSEVELT AVE
GRANTS NM
87020-2118
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-4446
  • Fax: 505-287-5213
Mailing address:
  • Phone: 505-287-4446
  • Fax: 505-287-5213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2024-0822
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: