Provider Demographics
NPI:1174302285
Name:LARSON, RAE (LCSW)
Entity type:Individual
Prefix:
First Name:RAE
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:447 TAMARACH DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-5243
Mailing Address - Country:US
Mailing Address - Phone:314-686-7997
Mailing Address - Fax:314-686-7998
Practice Address - Street 1:7280 NW 87TH TER STE C
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64153-3720
Practice Address - Country:US
Practice Address - Phone:314-686-7997
Practice Address - Fax:314-686-7998
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-27
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL26009721041S0200X
1041C0700X
MO20220002656104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No104100000XBehavioral Health & Social Service ProvidersSocial Worker