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General NPI Number Information
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NPI Number | 1497781496
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Entity Type | Individual
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Provider Name | PHILIP REED LARSEN JR. LICSW, LCSW
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Gender | Male
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Dates
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Enumeration Date | 06/23/2006
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Last Update Date | 10/12/2018
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Provider Practice Location Address
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Address Line | 1229 S SAINT FRANCIS DR STE B
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City | SANTA FE
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State | NM
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Zip | 87505-4052
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Country | US
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Telephone | 413-626-1094
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2139
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City | SANTA CRUZ
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State | NM
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Zip | 87567-2139
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Country | US
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Telephone | 413-626-1094
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C-09948
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 110336
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License Number State | MA
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