1124749890 NPI number — MRS. RACHEL MALLORN LARSON MSW

Table of content: MRS. RACHEL MALLORN LARSON MSW (NPI 1124749890)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124749890 NPI number — MRS. RACHEL MALLORN LARSON MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARSON
Provider First Name:
RACHEL
Provider Middle Name:
MALLORN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124749890
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
510 4TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BARABOO
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53913-2033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-434-3402
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1212 8TH ST STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARABOO
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53913-1875
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-434-5145
Provider Business Practice Location Address Fax Number:
608-355-0755
Provider Enumeration Date:
09/09/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  132608-121 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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