Basic Information
| Provider Information | |||||||||
| NPI: | 1194251298 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | CIARA | ||||||||
| MiddleName: | PEARLE | ||||||||
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| Credential: | CSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1820 SIDEWINDER DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | PARK CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840607563 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1820 SIDEWINDER DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | PARK CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840607563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356589199 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2017 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | Other Service Providers | Specialist | 1041C0700X | 12348470-3502 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.