Provider Demographics
NPI:1184195026
Name:LARSON, KATHERYN RENAY (CP60642390)
Entity Type:Individual
Prefix:MRS
First Name:KATHERYN
Middle Name:RENAY
Last Name:LARSON
Suffix:
Gender:F
Credentials:CP60642390
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10322 NE 132ND ST
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-2829
Mailing Address - Country:US
Mailing Address - Phone:425-823-3116
Mailing Address - Fax:425-820-3354
Practice Address - Street 1:10322 NE 132ND ST
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-2829
Practice Address - Country:US
Practice Address - Phone:425-823-3116
Practice Address - Fax:425-820-3354
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60642390101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)