Provider Demographics
NPI:1063677904
Name:LARSON, EMILIE ANN (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:EMILIE
Middle Name:ANN
Last Name:LARSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 SYCAMORE CIR
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3144
Mailing Address - Country:US
Mailing Address - Phone:631-675-1450
Mailing Address - Fax:
Practice Address - Street 1:115 CARLETON AVE
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-3619
Practice Address - Country:US
Practice Address - Phone:631-234-7807
Practice Address - Fax:631-234-8039
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-21
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker