Provider Demographics
NPI:1164308151
Name:LARSEN, AMBER MAE (MA)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:MAE
Last Name:LARSEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24407 VARGAS
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-8851
Mailing Address - Country:US
Mailing Address - Phone:541-285-0862
Mailing Address - Fax:
Practice Address - Street 1:4029 W MAIN ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-2763
Practice Address - Country:US
Practice Address - Phone:541-285-0862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-14
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451024474101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional