Healthcare Provider Details

I. General information

NPI: 1710801162
Provider Name (Legal Business Name): EVAN THOMAS LARSON LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6439 GARNERS FERRY RD
COLUMBIA SC
29209-1638
US

IV. Provider business mailing address

260 CIRCLE DR
PENDLETON SC
29670-8871
US

V. Phone/Fax

Practice location:
  • Phone: 803-776-4000
  • Fax:
Mailing address:
  • Phone: 843-330-9900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number18861
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: