Provider Demographics
NPI:1215396288
Name:LARSEN, HEIDI (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 W CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-2814
Mailing Address - Country:US
Mailing Address - Phone:309-557-1410
Mailing Address - Fax:
Practice Address - Street 1:902 S EAST ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701
Practice Address - Country:US
Practice Address - Phone:309-838-5282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-18
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0206601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical