Provider Demographics
NPI:1508145673
Name:LARSON, SHIRLEY MARIE (LSW)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:MARIE
Last Name:LARSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 PINE ST
Mailing Address - Street 2:2E4
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-6200
Mailing Address - Country:US
Mailing Address - Phone:570-506-3875
Mailing Address - Fax:
Practice Address - Street 1:454 PINE ST
Practice Address - Street 2:2E4
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-6200
Practice Address - Country:US
Practice Address - Phone:570-506-3875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW1287641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical