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General NPI Number Information
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NPI Number | 1538154679
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Entity Type | Individual
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Provider Name | MARLENA LARSON PSY.D.
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Gender | Female
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Dates
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Enumeration Date | 09/14/2005
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Last Update Date | 11/25/2008
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Provider Practice Location Address
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Address Line | 1320 WISCONSIN AVE
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City | RACINE
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State | WI
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Zip | 53403-1978
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Country | US
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Telephone | 262-687-2436
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Fax | 262-687-2495
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Provider Business Mailing Address
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Address Line | 425 4 1/2 MILE RD
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City | RACINE
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State | WI
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Zip | 53402
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Country | US
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Telephone | 262-456-0206
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2512-057
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License Number State | WI
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