1255424339 NPI number — LINDA L LARSON LCSW

Table of content: LINDA L LARSON LCSW (NPI 1255424339)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255424339 NPI number — LINDA L LARSON LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARSON
Provider First Name:
LINDA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
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:
1255424339
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8056 149TH AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRENORA
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58845
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-694-3692
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
316 2ND AVE W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLISTON
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
55880
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-774-4600
Provider Business Practice Location Address Fax Number:
701-774-4620
Provider Enumeration Date:
10/02/2006

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: 1041C0700X , with the licence number:  3301 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 021190 . This is a "BCBS" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 54516 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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