=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972914505
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KURT LAROSE MSW LCSW
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2014
-----------------------------------------------------
Last Update Date | 02/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1701 E HARVEST CIR
-----------------------------------------------------
City | PERRYVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63775-9330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-545-2886
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1701 E HARVEST CIR
-----------------------------------------------------
City | PERRYVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63775-9330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-545-2886
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PROPRIETOR
-----------------------------------------------------
Name | MR. KURT DOMINICK LAROSE
-----------------------------------------------------
Credential | LCSW LICSW
-----------------------------------------------------
Telephone | 850-545-2886
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | LC50081569
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW9297
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------