Provider Demographics
NPI:1184895997
Name:LARSON, ELIZABETH T
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:T
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 1:5621 LYNWOOD PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1035
Mailing Address - Country:US
Mailing Address - Phone:208-323-1473
Mailing Address - Fax:
Practice Address - Street 1:2176 E FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9024
Practice Address - Country:US
Practice Address - Phone:208-830-4036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC397101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0000 101 48195OtherREGENCE
IDQ4319OtherBLUE CROSS