Provider Demographics
NPI:1003504788
Name:LARSON, MICHELE J (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:J
Last Name:LARSON
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 SERRA ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-9244
Mailing Address - Country:US
Mailing Address - Phone:608-577-5742
Mailing Address - Fax:
Practice Address - Street 1:104 SERRA ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-9244
Practice Address - Country:US
Practice Address - Phone:608-577-5742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN276691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical