Basic Information
| Provider Information | |||||||||
| NPI: | 1588036545 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | LCSW, CSAC, ICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5005 N PIEDRAS ST | ||||||||
| Address2: | ATTENTION WBAMC | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799205002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157426382 | ||||||||
| FaxNumber: | 9155694890 | ||||||||
| Practice Location | |||||||||
| Address1: | 5005 N PIEDRAS ST | ||||||||
| Address2: | ATTENTION WBAMC | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799205002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157426382 | ||||||||
| FaxNumber: | 9155694890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2015 | ||||||||
| LastUpdateDate: | 10/29/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 8300-123 | WI | Y | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | 15603-132 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 15442-134 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.