Provider Demographics
NPI:1164418646
Name:LARSON, ANGELA RENAE (BS)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:RENAE
Last Name:LARSON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:MISS
Other - First Name:ANGELA
Other - Middle Name:RENAE
Other - Last Name:KARLSTAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:PO BOX 1030
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-6030
Mailing Address - Country:US
Mailing Address - Phone:605-886-0123
Mailing Address - Fax:605-886-5447
Practice Address - Street 1:123 19TH ST NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-2823
Practice Address - Country:US
Practice Address - Phone:605-886-0123
Practice Address - Fax:605-886-5447
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health