Provider Demographics
NPI:1891999264
Name:LARSEN, MICHAEL E (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:E
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:PO BOX 75
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MO
Mailing Address - Zip Code:65340-0075
Mailing Address - Country:US
Mailing Address - Phone:660-815-2520
Mailing Address - Fax:660-886-6658
Practice Address - Street 1:24620 KNOX DR
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MO
Practice Address - Zip Code:65340-4304
Practice Address - Country:US
Practice Address - Phone:660-815-2520
Practice Address - Fax:660-886-6658
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2011-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040357801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498373901Medicaid
MO2004035780OtherSTATE LICENSE #