Healthcare Provider Details

I. General information

NPI: 1538154679
Provider Name (Legal Business Name): MARLENA LARSON PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 11/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 WISCONSIN AVE
RACINE WI
53403-1978
US

IV. Provider business mailing address

425 4 1/2 MILE RD
RACINE WI
53402
US

V. Phone/Fax

Practice location:
  • Phone: 262-687-2436
  • Fax: 262-687-2495
Mailing address:
  • Phone: 262-456-0206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2512-057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: