MEDICARE: TRACY LARSON LMSW

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	104100000X	Social Worker	5726	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8680	OTHER	KS	PREFERRED HEALTH SYSTEMS
2	200919	OTHER	KS	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1447203278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY LARSON LMSW

Provider Business Mailing Address
First Line	:	635 N MAIN ST
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67203-3602
Country	:	US
Telephone Number	:	316-660-7600
Fax Number	:	316-383-7925

Provider Business Practice Location Address
First Line	:	1919 N AMIDON AVE
Second Line	:	STE. 100
City	:	WICHITA
State	:	KS
Zip	:	67203-2117
Country	:	US
Telephone Number	:	316-660-7540
Fax Number	:	316-660-7588

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

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	07/08/2007

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Directions to “ TRACY LARSON LMSW” Practice Location

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