Provider Demographics
NPI:1497781496
Name:LARSEN, PHILIP REED JR (LICSW, LCSW)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:REED
Last Name:LARSEN
Suffix:JR
Gender:M
Credentials:LICSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2139
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:NM
Mailing Address - Zip Code:87567-2139
Mailing Address - Country:US
Mailing Address - Phone:413-626-1094
Mailing Address - Fax:
Practice Address - Street 1:1229 S SAINT FRANCIS DR STE B
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4052
Practice Address - Country:US
Practice Address - Phone:413-626-1094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-099481041C0700X
MA1103361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP22857Medicare ID - Type Unspecified