Provider Demographics
NPI:1316048770
Name:LARSON, DAVID (LP)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 W CLARK ST
Mailing Address - Street 2:
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-2548
Mailing Address - Country:US
Mailing Address - Phone:507-373-7913
Mailing Address - Fax:507-373-7913
Practice Address - Street 1:244 W CLARK ST
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-2548
Practice Address - Country:US
Practice Address - Phone:507-373-7913
Practice Address - Fax:507-373-7913
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0618103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN411805759OtherBHP
MN103748000Medicaid
MN115228OtherUCARE AND SCHA
MN30235LAOtherBCBS
MN99099OtherPREFERRED ONE