Healthcare Provider Details

I. General information

NPI: 1003663360
Provider Name (Legal Business Name): CAITLIN ROSE LARSEN-MORALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2024
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 SHERWOOD AVE
RICHMOND VA
23220-1210
US

IV. Provider business mailing address

290 DEWEY AVE
STATEN ISLAND NY
10308-1541
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-3129
  • Fax:
Mailing address:
  • Phone: 917-796-1732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: