Provider Demographics
NPI:1720590383
Name:LARSEN, ANDREW JOHN (LCSW)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JOHN
Last Name:LARSEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9471
Mailing Address - Country:US
Mailing Address - Phone:435-233-4417
Mailing Address - Fax:
Practice Address - Street 1:405 EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9471
Practice Address - Country:US
Practice Address - Phone:435-233-4417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-03
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10834398-35011041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055266OtherMEDICARE PIN
UT8760003008007Medicaid
UT260022408OtherRAILROAD MEDICARE