Provider Demographics
NPI:1699392001
Name:LARSON, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:SOMONAUK
Mailing Address - State:IL
Mailing Address - Zip Code:60552-3162
Mailing Address - Country:US
Mailing Address - Phone:815-579-4581
Mailing Address - Fax:
Practice Address - Street 1:400 E NORTH ST
Practice Address - Street 2:
Practice Address - City:SOMONAUK
Practice Address - State:IL
Practice Address - Zip Code:60552-3162
Practice Address - Country:US
Practice Address - Phone:815-579-4581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490221521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical