Healthcare Provider Details

I. General information

NPI: 1750590477
Provider Name (Legal Business Name): JODY B LARSON LPC, ATRL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 12/29/2023
Certification Date: 12/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 ANGELS PATH
DE PERE WI
54115-4050
US

IV. Provider business mailing address

PO BOX 22040
GREEN BAY WI
54305-2040
US

V. Phone/Fax

Practice location:
  • Phone: 920-338-2855
  • Fax: 920-338-9270
Mailing address:
  • Phone: 920-445-7210
  • Fax: 920-445-7289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number62-036
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2479-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: