Basic Information
| Provider Information | |||||||||
| NPI: | 1336100932 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | MOLLY | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 123977 DEPT 3977 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753123977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374942921 | ||||||||
| FaxNumber: | 3734946523 | ||||||||
| Practice Location | |||||||||
| Address1: | 2829 4TH AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706017897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374807800 | ||||||||
| FaxNumber: | 3374744552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 05/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 71 | LA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YP2500X | 2394 | LA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.