Provider Demographics
NPI:1679711063
Name:LARSON, REBECCA (MSW LCSW)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364 SW KALMIA AVE
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:OR
Mailing Address - Zip Code:97146-7356
Mailing Address - Country:US
Mailing Address - Phone:928-246-5100
Mailing Address - Fax:
Practice Address - Street 1:2111 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3329
Practice Address - Country:US
Practice Address - Phone:503-338-7524
Practice Address - Fax:503-338-4019
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
ORL75751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor