Provider Demographics
NPI:1568036390
Name:LARSEN, CHRISTINA DANIELLE
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:DANIELLE
Last Name:LARSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2608 OLD FAIR RD
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-5271
Mailing Address - Country:US
Mailing Address - Phone:308-382-5297
Mailing Address - Fax:308-382-5315
Practice Address - Street 1:525 S 9TH AVE
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:NE
Practice Address - Zip Code:68822-2457
Practice Address - Country:US
Practice Address - Phone:308-872-5040
Practice Address - Fax:308-872-5060
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health