Provider Demographics
NPI:1184219974
Name:LARSON, MELISSA GORONI (LICSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:GORONI
Last Name:LARSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9400 ZANE AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-1814
Mailing Address - Country:US
Mailing Address - Phone:763-762-8800
Mailing Address - Fax:
Practice Address - Street 1:111 HUNDERTMARK RD STE 205N
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1586
Practice Address - Country:US
Practice Address - Phone:952-903-1350
Practice Address - Fax:952-426-3856
Is Sole Proprietor?:No
Enumeration Date:2021-03-04
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN268441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical