Provider Demographics
NPI:1962734335
Name:LARSON, KRISTIN ANN
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ANN
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 1:4110 AVENUE D
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4650
Mailing Address - Country:US
Mailing Address - Phone:308-635-3171
Mailing Address - Fax:308-635-7026
Practice Address - Street 1:4110 AVENUE D
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4650
Practice Address - Country:US
Practice Address - Phone:308-635-3171
Practice Address - Fax:308-635-7026
Is Sole Proprietor?:No
Enumeration Date:2010-02-09
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1141101YM0800X
NE1980101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional