MEDICARE: MR. PHILIP REED LARSEN JR. LICSW, 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	C-09948	NM
2	1041C0700X	Clinical Social Worker	110336	MA

General Provider Information

NPI Number	:	1497781496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PHILIP REED LARSEN JR. LICSW, LCSW

Provider Business Mailing Address
First Line	:	PO BOX 2139
Second Line	:
City	:	SANTA CRUZ
State	:	NM
Zip	:	87567-2139
Country	:	US
Telephone Number	:	413-626-1094
Fax Number	:

Provider Business Practice Location Address
First Line	:	1229 S SAINT FRANCIS DR STE B
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-4052
Country	:	US
Telephone Number	:	413-626-1094
Fax Number	:

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

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	10/12/2018

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Directions to “ MR. PHILIP REED LARSEN JR. LICSW, LCSW” Practice Location

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