Provider Demographics
NPI:1588954812
Name:LARSON, DEBORAH DIANE (LADC)
Entity type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:DIANE
Last Name:LARSON
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 3RD AVE SW
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063-1468
Mailing Address - Country:US
Mailing Address - Phone:320-629-1362
Mailing Address - Fax:320-629-3454
Practice Address - Street 1:645 3RD AVE SW
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063-1468
Practice Address - Country:US
Practice Address - Phone:320-629-1362
Practice Address - Fax:320-629-3454
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301810101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)