=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215564257
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHRYN LAROE LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2020
-----------------------------------------------------
Last Update Date | 03/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 846 F AVE APT A
-----------------------------------------------------
City | CORONADO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92118-2589
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-881-7443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 846 F AVE APT A
-----------------------------------------------------
City | CORONADO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92118-2589
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-881-7443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 93747
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------