Provider Demographics
NPI:1588257976
Name:LARSEN, KIMBERLY (LAC CADAC V)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:LAC CADAC V
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 W MORGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-2244
Mailing Address - Country:US
Mailing Address - Phone:219-307-0086
Mailing Address - Fax:
Practice Address - Street 1:612 W MORGAN AVE
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-2244
Practice Address - Country:US
Practice Address - Phone:219-307-0086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN86000384A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)