Provider Demographics
NPI:1306984497
Name:LARSON, CLAUDETTE M (LICSW)
Entity type:Individual
Prefix:MRS
First Name:CLAUDETTE
Middle Name:M
Last Name:LARSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MRS
Other - First Name:CLAUDETTE
Other - Middle Name:M
Other - Last Name:CARLSON-LARSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:640 ATLANTIC AVENUE
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:MN
Mailing Address - Zip Code:56215
Mailing Address - Country:US
Mailing Address - Phone:320-843-3454
Mailing Address - Fax:320-843-4692
Practice Address - Street 1:640 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:MN
Practice Address - Zip Code:56215
Practice Address - Country:US
Practice Address - Phone:320-843-3454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN167651041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN411910086OtherCORP HEALTH
MN600074381OtherMAGELLAN
MN1050870OtherBHP PREFERRED ONE
MN046D1CAOtherBCBS
MN76660100Medicaid
MNHP78786OtherHEALTH PARTNERS
MN152193OtherUCARE
MN6984497OtherUBH
MN6984497OtherUBH