=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174302285
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAE LARSON LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2023
-----------------------------------------------------
Last Update Date | 08/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7280 NW 87TH TER STE C
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64153-3720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-686-7997
-----------------------------------------------------
Fax | 314-686-7998
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 447 TAMARACH DR
-----------------------------------------------------
City | EDWARDSVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62025-5243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-686-7997
-----------------------------------------------------
Fax | 314-686-7998
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041S0200X
-----------------------------------------------------
Taxonomy Name | School Social Worker
-----------------------------------------------------
License Number | 2600972
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 20220002656
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------