MEDICARE: MR. MATTHEW G. LARSON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	360939-3501	UT

General Provider Information

NPI Number	:	1326002437
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATTHEW G. LARSON LCSW

Provider Business Mailing Address
First Line	:	PO BOX 1221
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84101-1221
Country	:	US
Telephone Number	:	801-599-6396
Fax Number	:	801-599-6396

Provider Business Practice Location Address
First Line	:	24 S 600 E
Second Line	:	STE. 6
City	:	SLC
State	:	UT
Zip	:	84102
Country	:	US
Telephone Number	:	801-599-6396
Fax Number	:	801-521-0688

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2006
Last Update Date	:	02/25/2008

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