Provider Demographics
NPI:1104911676
Name:KURISKO, LARAINE PATRICIA (PHD, LP)
Entity type:Individual
Prefix:DR
First Name:LARAINE
Middle Name:PATRICIA
Last Name:KURISKO
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18664 OVERLAND TRAIL
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-4186
Mailing Address - Country:US
Mailing Address - Phone:952-974-3764
Mailing Address - Fax:
Practice Address - Street 1:4005 WEST 65TH STREET
Practice Address - Street 2:SUITE 104
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:952-926-2424
Practice Address - Fax:952-926-3454
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4466103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical