Provider Demographics
NPI:1194731091
Name:LARSON, DEREK R (LCSW)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:R
Last Name:LARSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75TH MEDICAL GROUP
Mailing Address - Street 2:7321 BALMER STREET BUILDING 570
Mailing Address - City:HILL AFB
Mailing Address - State:UT
Mailing Address - Zip Code:84056
Mailing Address - Country:US
Mailing Address - Phone:801-777-7909
Mailing Address - Fax:
Practice Address - Street 1:75TH MEDICAL GROUP
Practice Address - Street 2:7321 BALMER STREET BUILDING 570
Practice Address - City:HILL AFB
Practice Address - State:UT
Practice Address - Zip Code:84056
Practice Address - Country:US
Practice Address - Phone:801-777-7909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4941733-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000060907Medicare PIN