Provider Demographics
NPI:1083326326
Name:LARSON, BETHANY ANNE
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:ANNE
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 1:1701 CURVE CREST BLVD W STE 104
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6181
Mailing Address - Country:US
Mailing Address - Phone:651-342-1883
Mailing Address - Fax:651-342-2231
Practice Address - Street 1:1701 CURVE CREST BLVD W STE 104
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6181
Practice Address - Country:US
Practice Address - Phone:651-342-1883
Practice Address - Fax:651-342-2231
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician