Provider Demographics
NPI:1083712301
Name:LARSEN, WILLIAM WALTER (PHD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:WALTER
Last Name:LARSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 ITASCA ST
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-2965
Mailing Address - Country:US
Mailing Address - Phone:218-327-2295
Mailing Address - Fax:218-327-2295
Practice Address - Street 1:525 ITASCA ST
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-2965
Practice Address - Country:US
Practice Address - Phone:218-327-2295
Practice Address - Fax:218-327-2295
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0562103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical