1508066929 NPI number — MR. JOHN STEVEN LARDY MSW, LICSW

Table of content: MR. JOHN STEVEN LARDY MSW, LICSW (NPI 1508066929)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508066929 NPI number — MR. JOHN STEVEN LARDY MSW, LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARDY
Provider First Name:
JOHN
Provider Middle Name:
STEVEN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LICSW
Provider Gender Code:
M

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:
1508066929
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5836 ABBOTT AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55410-2810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-848-1722
Provider Business Mailing Address Fax Number:
952-996-2058

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13750 CROSSTOWN DR NW STE 310
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANDOVER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55304-5853
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-482-9598
Provider Business Practice Location Address Fax Number:
763-482-9598
Provider Enumeration Date:
07/23/2007

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:  4079 , 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: 4079 . This is a "MINNESOTA BOARD OF SOCIAL" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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