Basic Information
| Provider Information | |||||||||
| NPI: | 1215302716 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | SUTTON | ||||||||
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| Credential: | LCSW-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2057 PULASKI HWY | ||||||||
| Address2: | STE 4 | ||||||||
| City: | NORTH EAST | ||||||||
| State: | MD | ||||||||
| PostalCode: | 219013744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4438774044 | ||||||||
| FaxNumber: | 4439670077 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 W HIGH ST STE 204 | ||||||||
| Address2: | |||||||||
| City: | ELKTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 219218611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106200008 | ||||||||
| FaxNumber: | 4106201999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2015 | ||||||||
| LastUpdateDate: | 07/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 16322 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.