Provider Demographics
NPI:1902480676
Name:LARSEN, KELLY LYN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYN
Last Name:LARSEN
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 1:555 DICKENS LANDING DR
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-1267
Mailing Address - Country:US
Mailing Address - Phone:936-933-2770
Mailing Address - Fax:
Practice Address - Street 1:2200 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-4058
Practice Address - Country:US
Practice Address - Phone:936-933-2770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77195101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty