Provider Demographics
NPI:1679507966
Name:LARSON, STACEY (LSCSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:WESCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSCSW
Mailing Address - Street 1:560 N. EXPOSITION
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203
Mailing Address - Country:US
Mailing Address - Phone:316-264-8317
Mailing Address - Fax:316-264-0347
Practice Address - Street 1:560 N. EXPOSITION
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203
Practice Address - Country:US
Practice Address - Phone:316-264-8317
Practice Address - Fax:316-264-0347
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS22831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical