Provider Demographics
NPI:1154829497
Name:LARSON, MICHAEL A (LICSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:LARSON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 E COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-2010
Mailing Address - Country:US
Mailing Address - Phone:507-532-3236
Mailing Address - Fax:507-532-0240
Practice Address - Street 1:1212 E COLLEGE DR
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-2010
Practice Address - Country:US
Practice Address - Phone:507-532-3236
Practice Address - Fax:507-532-0240
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN208231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN20823OtherLICSW LICENSE