Provider Demographics
NPI:1306949938
Name:LARSEN, KATHLEEN R (LCPC)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:R
Last Name:LARSEN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 MOODY ST
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-1536
Mailing Address - Country:US
Mailing Address - Phone:800-434-3000
Mailing Address - Fax:
Practice Address - Street 1:50 MOODY ST
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072
Practice Address - Country:US
Practice Address - Phone:800-434-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC4683101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39711200Medicaid