Provider Demographics
NPI:1023221967
Name:LAROSE, KURT DOMINICK (LCSW, LICSW)
Entity Type:Individual
Prefix:MR
First Name:KURT
Middle Name:DOMINICK
Last Name:LAROSE
Suffix:
Gender:M
Credentials:LCSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 N KINGSHIGHWAY ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PERRYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63775-1367
Mailing Address - Country:US
Mailing Address - Phone:850-545-2886
Mailing Address - Fax:
Practice Address - Street 1:12 N KINGS HWY STE 101
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:MO
Practice Address - Zip Code:63775-1367
Practice Address - Country:US
Practice Address - Phone:573-547-3116
Practice Address - Fax:573-547-2963
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW92971041C0700X
DCLC500815691041C0700X
MO20200230421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12243893OtherCAQH
FLZ176VOtherBLUE CROSS BLUE SHIELD
FL9041674OtherAETNA
FLZ176VOtherBLUE CROSS BLUE SHIELD