Provider Demographics
NPI:1386055168
Name:LARSON, KELLY (BSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6809 BEBE CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-2501
Mailing Address - Country:US
Mailing Address - Phone:502-381-2137
Mailing Address - Fax:502-964-8771
Practice Address - Street 1:6809 BEBE CT.
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219
Practice Address - Country:US
Practice Address - Phone:502-381-2137
Practice Address - Fax:502-964-8771
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator