MEDICARE: MISS VALERIE ANN LARSON BGS, BCABA

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	103K00000X	Behavior Analyst	0-08-2635

General Provider Information

NPI Number	:	1548407026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS VALERIE ANN LARSON BGS, BCABA

Provider Business Mailing Address
First Line	:	1120 ENCINITAS PT
Second Line	:	APT 201
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-9109
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1115 ELKTON DR
Second Line	:	SUITE 403
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-8507
Country	:	US
Telephone Number	:	719-494-9067
Fax Number	:	719-570-0386

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

Provider Enumeration Date	:	01/20/2009
Last Update Date	:	01/20/2009

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