Provider Demographics
NPI:1194711085
Name:OLSON-LARSON, TARA RENAE (MA LPC MH)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:RENAE
Last Name:OLSON-LARSON
Suffix:
Gender:F
Credentials:MA LPC MH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 S CARNEGIE PL
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-2360
Mailing Address - Country:US
Mailing Address - Phone:605-323-2345
Mailing Address - Fax:605-323-2822
Practice Address - Street 1:4105 S CARNEGIE PL
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-2360
Practice Address - Country:US
Practice Address - Phone:605-323-2345
Practice Address - Fax:605-323-2822
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC1084101YM0800X
SDLPCMH2120101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6575440Medicaid