Provider Demographics
NPI:1972119675
Name:LARSON, POLLY KATHRYN
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:KATHRYN
Last Name:LARSON
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 1:25 STATEN PL
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-1140
Mailing Address - Country:US
Mailing Address - Phone:317-250-6176
Mailing Address - Fax:
Practice Address - Street 1:580 E CARMEL DR
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-3317
Practice Address - Country:US
Practice Address - Phone:317-564-8332
Practice Address - Fax:317-660-2151
Is Sole Proprietor?:No
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99099767A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health