Provider Demographics
NPI:1619522356
Name:LARSEN, MADELEINE FISHER
Entity Type:Individual
Prefix:MISS
First Name:MADELEINE
Middle Name:FISHER
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 1:529 E PALACE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-2200
Mailing Address - Country:US
Mailing Address - Phone:505-920-4296
Mailing Address - Fax:
Practice Address - Street 1:529 E PALACE AVE
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-2200
Practice Address - Country:US
Practice Address - Phone:505-920-4296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician