Basic Information
| Provider Information | |||||||||
| NPI: | 1124789300 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSH | ||||||||
| FirstName: | KELSEY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 507 WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | THREE RIVERS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490931433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2695350438 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2675 COURT DR # B | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280541478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048244999 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2022 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-21-53254 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.