Provider Demographics
NPI:1679888754
Name:LARSEN, JULIE
Entity type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:WOOD
Other - Last Name:LARSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CSW
Mailing Address - Street 1:3944 S 400 E
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-1600
Mailing Address - Country:US
Mailing Address - Phone:801-261-1442
Mailing Address - Fax:
Practice Address - Street 1:3944 S 400 E
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-1600
Practice Address - Country:US
Practice Address - Phone:801-261-1442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2011-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT70164213502104100000X
UT701642135011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker