Provider Demographics
NPI:1477769172
Name:DAHL, LARRY M (LCSW)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:M
Last Name:DAHL
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 1:1630 S BROWNLEE BLVD
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78404-3134
Mailing Address - Country:US
Mailing Address - Phone:361-886-6900
Mailing Address - Fax:
Practice Address - Street 1:1546 S BROWNLEE BLVD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-3142
Practice Address - Country:US
Practice Address - Phone:361-886-6900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX398411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J7101Medicare PIN