Provider Demographics
NPI:1528487972
Name:LARSON, DANIELLE NICOLE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:NICOLE
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 COMMERCIAL ST
Mailing Address - Street 2:APT. 332
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-1319
Mailing Address - Country:US
Mailing Address - Phone:651-808-0762
Mailing Address - Fax:
Practice Address - Street 1:240 E HURON ST
Practice Address - Street 2:MCGAW MEDICAL CENTER OF NORTHWESTERN UNIVSERSITY
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2909
Practice Address - Country:US
Practice Address - Phone:312-503-7975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-14
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1458602084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty