Provider Demographics
NPI:1033750161
Name:LARSON, MARLENA SHAREA
Entity Type:Individual
Prefix:
First Name:MARLENA
Middle Name:SHAREA
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:672 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-1705
Mailing Address - Country:US
Mailing Address - Phone:717-945-2555
Mailing Address - Fax:
Practice Address - Street 1:672 FRONT ST
Practice Address - Street 2:
Practice Address - City:LITITZ
Practice Address - State:PA
Practice Address - Zip Code:17543-1705
Practice Address - Country:US
Practice Address - Phone:717-945-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA25206213171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator