Provider Demographics
NPI:1053343707
Name:LARSEN, KENNETH A (DMIN, PHD, ABMP)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:LARSEN
Suffix:
Gender:M
Credentials:DMIN, PHD, ABMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 N ELDORADO AVE
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-1229
Mailing Address - Country:US
Mailing Address - Phone:617-413-2328
Mailing Address - Fax:617-334-7845
Practice Address - Street 1:34 N ELDORADO AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-1229
Practice Address - Country:US
Practice Address - Phone:617-413-2328
Practice Address - Fax:617-334-7845
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPSY2944MA103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
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MAW03054Medicare UPIN
MA013709Medicare UPIN
MA25537300Medicare UPIN
MA32804Medicare UPIN
MAW03054Medicare ID - Type Unspecified