Provider Demographics
NPI:1902135247
Name:LARSEN, ALICE J (MASTERS STUDENT)
Entity Type:Individual
Prefix:MS
First Name:ALICE
Middle Name:J
Last Name:LARSEN
Suffix:
Gender:F
Credentials:MASTERS STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 14TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-423-0203
Mailing Address - Fax:360-577-0269
Practice Address - Street 1:2700 SIMPSON AVENUE
Practice Address - Street 2:STE. 101
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520
Practice Address - Country:US
Practice Address - Phone:360-612-0012
Practice Address - Fax:360-532-0670
Is Sole Proprietor?:No
Enumeration Date:2009-12-16
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60878870101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2107606Medicaid