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NPI Code Detail

MEDICARE: DR. MARLENA LARSON PSY.D.

MEDICARE: DR. MARLENA LARSON PSY.D.
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
1103TC0700XClinical Psychologist2512-057WI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1538154679
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. MARLENA LARSON PSY.D.
Provider Business Mailing Address
First Line : 425 4 1/2 MILE RD
Second Line :
City : RACINE
State : WI
Zip : 53402
Country : US
Telephone Number : 262-456-0206
Fax Number :
Provider Business Practice Location Address
First Line : 1320 WISCONSIN AVE
Second Line :
City : RACINE
State : WI
Zip : 53403-1978
Country : US
Telephone Number : 262-687-2436
Fax Number : 262-687-2495
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/14/2005
Last Update Date : 11/25/2008

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