1174972715 NPI number — ANNETTE MARIE LARSON M.A., L.P.C., LADC

Table of content: ANNETTE MARIE LARSON M.A., L.P.C., LADC (NPI 1174972715)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174972715 NPI number — ANNETTE MARIE LARSON M.A., L.P.C., LADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARSON
Provider First Name:
ANNETTE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A., L.P.C., LADC
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:
1174972715
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3328 92ND DR NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLAINE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55449-6851
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-444-1321
Provider Business Mailing Address Fax Number:
763-785-8111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
199 COON RAPIDS BLVD NW
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
COON RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55433-5831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-785-8111
Provider Business Practice Location Address Fax Number:
763-785-8111
Provider Enumeration Date:
06/05/2016

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: 101YA0400X , with the licence number:  303923 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 01859 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01859 . This is a "MINNESOTA BOARD OF BEHAVIORAL HEALTH AND THERAPY,LICENSED PROFESSIONAL COUNSELOR" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 7078 . This is a "MINNESOTA CERTIFICATION BOARD, ALCOHOL AND DRUG COUNSELOR-MINNESOTA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 303923 . This is a "MINNESOTA BOARD OF BEHAVIORAL HEALTH AND THERAPY, ALCOHOL AND DRUG COUNSELOR" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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