Provider Demographics
NPI:1952480972
Name:LARSEN, KATHIE G (PHD)
Entity Type:Individual
Prefix:
First Name:KATHIE
Middle Name:G
Last Name:LARSEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W MERCER ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98119-3995
Mailing Address - Country:US
Mailing Address - Phone:206-284-3237
Mailing Address - Fax:206-281-5333
Practice Address - Street 1:200 W MERCER ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98119-3995
Practice Address - Country:US
Practice Address - Phone:206-284-3237
Practice Address - Fax:206-281-5333
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00000634103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7126360Medicaid
WA7126360Medicaid