Provider Demographics
NPI:1063010130
Name:LARSON, ANGELA G
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:G
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 1:165 E HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-2629
Mailing Address - Country:US
Mailing Address - Phone:509-684-4597
Mailing Address - Fax:509-684-5286
Practice Address - Street 1:1211 MERRIAM ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:WA
Practice Address - Zip Code:99122-8654
Practice Address - Country:US
Practice Address - Phone:509-725-3001
Practice Address - Fax:509-725-1609
Is Sole Proprietor?:No
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61099017101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor