Basic Information
| Provider Information | |||||||||
| NPI: | 1982941027 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1550N CRESTMONT DR A | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836422177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082884200 | ||||||||
| FaxNumber: | 2082884279 | ||||||||
| Practice Location | |||||||||
| Address1: | 16 12TH AVE S | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | NAMPA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836513936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084896866 | ||||||||
| FaxNumber: | 2084756025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2013 | ||||||||
| LastUpdateDate: | 12/10/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW--33509 | ID | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.