Provider Demographics
NPI:1841627502
Name:LARSON, COLETTE (MSW, LISW-S)
Entity type:Individual
Prefix:
First Name:COLETTE
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:MSW, LISW-S
Other - Prefix:
Other - First Name:COLETTE
Other - Middle Name:
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4629 AICHOLTZ RD.
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45244-1557
Mailing Address - Country:US
Mailing Address - Phone:513-752-1555
Mailing Address - Fax:
Practice Address - Street 1:4633 AICHOLTZ RD.
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45244-4524
Practice Address - Country:US
Practice Address - Phone:513-752-1555
Practice Address - Fax:513-752-1555
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH31-0952668Medicaid