Provider Demographics
NPI:1699815423
Name:LARSON, KIMBERLY J (MS)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:J
Last Name:LARSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 E 20TH ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-0928
Mailing Address - Country:US
Mailing Address - Phone:417-627-9601
Mailing Address - Fax:
Practice Address - Street 1:1505 E 20TH ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-0928
Practice Address - Country:US
Practice Address - Phone:417-627-9601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006036429101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health