Provider Demographics
NPI:1053865915
Name:LARSEN, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:LARSEN
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 1:211 S 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80601-2581
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 S 21ST AVE
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-2581
Practice Address - Country:US
Practice Address - Phone:303-655-9065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical