Basic Information
| Provider Information | |||||||||
| NPI: | 1558796128 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | KEVIN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH SALT LAKE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841153164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3856465000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 344 E 100 S STE 301 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841111727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014284257 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2013 | ||||||||
| LastUpdateDate: | 05/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 76799 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 10516521-3501 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.