Basic Information
| Provider Information | |||||||||
| NPI: | 1003078155 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10000 BAY PINES BLVD | ||||||||
| Address2: | BAY PINES VAHCS | ||||||||
| City: | BAY PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273986661 | ||||||||
| FaxNumber: | 7273989567 | ||||||||
| Practice Location | |||||||||
| Address1: | 10000 BAY PINES BLVD | ||||||||
| Address2: | BAY PINES VAHCS | ||||||||
| City: | BAY PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273986661 | ||||||||
| FaxNumber: | 7273989567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2008 | ||||||||
| LastUpdateDate: | 11/28/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 071056 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.