Basic Information
| Provider Information | |||||||||
| NPI: | 1700952397 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LIMHP, LPC, MAC, ACS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 N 60TH ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025540520 | ||||||||
| FaxNumber: | 4025518797 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 JOEL DR | ||||||||
| Address2: | |||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704126881 | ||||||||
| FaxNumber: | 2704126889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2006 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | P401 | NE | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 1954 | NE | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 1080 | NE | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 10025315600 | 05 | NE | MEDICAID | 10025224900 | 05 | NE | MEDICAID | 47037661202 | 05 | NE | MEDICAID |