MEDICARE: DANETTE LEE LARSEN CMHC

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	101YM0800X	Mental Health Counselor	6823638-6004	UT

General Provider Information

NPI Number	:	1649733205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANETTE LEE LARSEN CMHC

Provider Business Mailing Address
First Line	:	613 E FORT UNION BLVD STE 104
Second Line	:
City	:	MIDVALE
State	:	UT
Zip	:	84047-5531
Country	:	US
Telephone Number	:	801-984-1717
Fax Number	:	801-984-1720

Provider Business Practice Location Address
First Line	:	613 E FORT UNION BLVD STE 104
Second Line	:
City	:	MIDVALE
State	:	UT
Zip	:	84047-5531
Country	:	US
Telephone Number	:	801-984-1717
Fax Number	:	801-984-1720

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

Provider Enumeration Date	:	04/10/2019
Last Update Date	:	06/11/2019

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