Provider Demographics
NPI:1053812461
Name:LARSON, KALEB ORVILLE (MS)
Entity type:Individual
Prefix:
First Name:KALEB
Middle Name:ORVILLE
Last Name:LARSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:MARTY
Other - Middle Name:ORVILLE
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:GIBAULT CARE INC.
Mailing Address - Street 2:6401 S. US HWY 41
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47805-4749
Mailing Address - Country:US
Mailing Address - Phone:812-299-1156
Mailing Address - Fax:812-299-0118
Practice Address - Street 1:6401 S. US HWY 41
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47805-4749
Practice Address - Country:US
Practice Address - Phone:812-299-1156
Practice Address - Fax:812-299-0118
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39004107A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health