Healthcare Provider Details

I. General information

NPI: 1568931780
Provider Name (Legal Business Name): KRISTIN LARSON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2018
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 NE 61ST ST STE 202
VANCOUVER WA
98665-8756
US

IV. Provider business mailing address

PO BOX 1533 454 N 1ST ST
KALAMA WA
98625
US

V. Phone/Fax

Practice location:
  • Phone: 509-306-2369
  • Fax:
Mailing address:
  • Phone: 509-306-2369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLW60892105
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: