Provider Demographics
NPI:1992475156
Name:LARSON, TAMARA NICOLE (NONE)
Entity type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:NICOLE
Last Name:LARSON
Suffix:
Gender:
Credentials:NONE
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:
Other - Last Name:EHRICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1547 30TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-5149
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1910 AGA DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-1796
Practice Address - Country:US
Practice Address - Phone:218-287-4338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician