Provider Demographics
NPI:1427194299
Name:LARSON, NATHAN (LCSW)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 N GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63106-1621
Mailing Address - Country:US
Mailing Address - Phone:314-652-4100
Mailing Address - Fax:314-289-6597
Practice Address - Street 1:915 N GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106-1621
Practice Address - Country:US
Practice Address - Phone:314-652-4100
Practice Address - Fax:314-289-6597
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOSW0010561041C0700X
MO0010561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO562150OtherVALUE OPTIONS PROV NUMBER