Provider Demographics
NPI:1942635735
Name:LARSON, SIDRA ANN (LCPC)
Entity type:Individual
Prefix:
First Name:SIDRA
Middle Name:ANN
Last Name:LARSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1043 E PARK BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-7711
Mailing Address - Country:US
Mailing Address - Phone:208-505-9786
Mailing Address - Fax:
Practice Address - Street 1:1043 E PARK BLVD STE 101
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-7711
Practice Address - Country:US
Practice Address - Phone:208-505-9786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-11
Last Update Date:2025-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14237330-6004101YM0800X
AZ24404101YM0800X
ID5968101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health