Provider Demographics
NPI:1164583407
Name:LARSON, RUTH A (LCPC)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:A
Last Name:LARSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:934 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2357
Mailing Address - Country:US
Mailing Address - Phone:208-888-1320
Mailing Address - Fax:208-888-3018
Practice Address - Street 1:934 E 5TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2357
Practice Address - Country:US
Practice Address - Phone:208-888-1320
Practice Address - Fax:208-888-3018
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC278101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDQ6454OtherBLUE CROSS