Provider Demographics
NPI:1750590477
Name:LARSON, JODY B (LPC, ATRL)
Entity type:Individual
Prefix:MRS
First Name:JODY
Middle Name:B
Last Name:LARSON
Suffix:
Gender:F
Credentials:LPC, ATRL
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 22040
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2040
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:1325 ANGELS PATH
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-4050
Practice Address - Country:US
Practice Address - Phone:920-338-2855
Practice Address - Fax:920-338-9270
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI62-036221700000X
WI2479-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
497057OtherNATIONAL BOARD FOR CERTIFIED COUNSELORS