Healthcare Provider Details

I. General information

NPI: 1497781496
Provider Name (Legal Business Name): PHILIP REED LARSEN JR. LICSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 10/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 S SAINT FRANCIS DR STE B
SANTA FE NM
87505-4052
US

IV. Provider business mailing address

PO BOX 2139
SANTA CRUZ NM
87567-2139
US

V. Phone/Fax

Practice location:
  • Phone: 413-626-1094
  • Fax:
Mailing address:
  • Phone: 413-626-1094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-09948
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number110336
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: