MEDICARE: MRS. MEGAN SUSANNE LARSON MSW, LCSW, ACSW

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	34004808A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	076965	OTHER	IN	SIHO
2	000000381518	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1992850085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MEGAN SUSANNE LARSON MSW, LCSW, ACSW

Provider Business Mailing Address
First Line	:	3220 MIDDLE DR
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47203-4426
Country	:	US
Telephone Number	:	812-378-4428
Fax Number	:	812-378-4427

Provider Business Practice Location Address
First Line	:	3220 MIDDLE DR
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47203-4426
Country	:	US
Telephone Number	:	812-378-4428
Fax Number	:	812-378-4427

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

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	07/08/2007

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