Provider Demographics
NPI:1114041308
Name:LARSON, TOSHA L (PHD)
Entity Type:Individual
Prefix:MS
First Name:TOSHA
Middle Name:L
Last Name:LARSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 COMMUNITY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-8804
Mailing Address - Country:US
Mailing Address - Phone:660-885-8131
Mailing Address - Fax:
Practice Address - Street 1:1000 W NIFONG BLVD BLDG 6
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5615
Practice Address - Country:US
Practice Address - Phone:844-853-8937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015016435103TC0700X, 103TC0700X
KSTLMLP1012103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS840273OtherBLUE SHIELD