Provider Demographics
NPI:1235116575
Name:NUSSBAUM, LARRY R (LSCSW)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:R
Last Name:NUSSBAUM
Suffix:
Gender:M
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57950 LEAVENWORTH ST
Mailing Address - Street 2:
Mailing Address - City:MCCONNELL AFB
Mailing Address - State:KS
Mailing Address - Zip Code:67221-3506
Mailing Address - Country:US
Mailing Address - Phone:316-759-5864
Mailing Address - Fax:316-759-5038
Practice Address - Street 1:547 N ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-3273
Practice Address - Country:US
Practice Address - Phone:316-641-4925
Practice Address - Fax:316-684-5448
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS08581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS004691Medicare ID - Type UnspecifiedBCBS AND MEDICARE NUMBER