Provider Demographics
NPI:1457321259
Name:LARSEN, LESLIE ANNE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:ANNE
Last Name:LARSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 E 3900 S
Mailing Address - Street 2:#250-A
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1215
Mailing Address - Country:US
Mailing Address - Phone:801-284-4915
Mailing Address - Fax:801-284-4901
Practice Address - Street 1:1141 E 3900 S
Practice Address - Street 2:#250-A
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1215
Practice Address - Country:US
Practice Address - Phone:801-284-4915
Practice Address - Fax:801-284-4901
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT136415-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT136415-3501OtherDOPL NUMBER
UT003114002Medicare PIN
UT136415-3501OtherDOPL NUMBER
UT004662151Medicare PIN
UTU000074993Medicare PIN