Provider Demographics
NPI:1467146506
Name:LARSEN, BREANNA NICOLE
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:NICOLE
Last Name:LARSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:938 WINDROW DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE CANADA
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1033
Mailing Address - Country:US
Mailing Address - Phone:651-352-1256
Mailing Address - Fax:
Practice Address - Street 1:938 WINDROW DR
Practice Address - Street 2:
Practice Address - City:LITTLE CANADA
Practice Address - State:MN
Practice Address - Zip Code:55109-1033
Practice Address - Country:US
Practice Address - Phone:653-352-1256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-02
Last Update Date:2023-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician