Provider Demographics
NPI:1417014168
Name:LARSON, CAROLYN (LMFT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3490 LEXINGTON AVE N
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-8074
Mailing Address - Country:US
Mailing Address - Phone:651-486-3808
Mailing Address - Fax:651-486-3858
Practice Address - Street 1:3490 LEXINGTON AVE N
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-8074
Practice Address - Country:US
Practice Address - Phone:651-486-3808
Practice Address - Fax:651-486-3858
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1277106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist