Provider Demographics
NPI:1083936181
Name:BLAIR, LARRY VAUGHN (LICSW)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:VAUGHN
Last Name:BLAIR
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2970 JUDICIAL ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337
Mailing Address - Country:US
Mailing Address - Phone:952-224-8990
Mailing Address - Fax:952-224-8991
Practice Address - Street 1:2970 JUDICIAL ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337
Practice Address - Country:US
Practice Address - Phone:952-224-8990
Practice Address - Fax:952-224-8991
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN107271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN708390400Medicaid
MN708390400Medicaid