Provider Demographics
NPI:1679655856
Name:LARSON, SHANE MICHAEL (MS, LPC-MH)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:MICHAEL
Last Name:LARSON
Suffix:
Gender:M
Credentials:MS, LPC-MH
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 1131
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-6131
Mailing Address - Country:US
Mailing Address - Phone:605-520-0157
Mailing Address - Fax:
Practice Address - Street 1:100 S MAPLE
Practice Address - Street 2:SUITE 204
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-3678
Practice Address - Country:US
Practice Address - Phone:605-520-0157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPCMH2210101YP2500X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5200010Medicaid