Individual
MR. SHANE MICHAEL LARSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.S., LPC-MH
Contact information
Practice address
100 S MAPLE, SUITE 204, WATERTOWN, SD 57201-3678
(605) 520-0157
Mailing address
PO BOX 1131, WATERTOWN, SD 57201-6131
(605) 520-0157
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
—
101YP2500X
Professional Counselor
Primary
LPCMH2210
SD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
5200010
—
SD
Enumeration date
10/19/2006
Last updated
04/24/2017
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