Provider Demographics
NPI:1467204305
Name:DERKSEN, LARA (MA)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:DERKSEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:
Other - Last Name:ELVEHJEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:3800 AMERICAN BLVD W STE 740
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-4422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3800 AMERICAN BLVD W STE 740
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-4422
Practice Address - Country:US
Practice Address - Phone:612-925-8365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician