Provider Demographics
NPI:1497360200
Name:LARSON, SADE ALISIA
Entity Type:Individual
Prefix:
First Name:SADE
Middle Name:ALISIA
Last Name:LARSON
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 1:205 14TH AVE E
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-4500
Mailing Address - Country:US
Mailing Address - Phone:320-774-3436
Mailing Address - Fax:
Practice Address - Street 1:205 14TH AVE E
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-4500
Practice Address - Country:US
Practice Address - Phone:320-774-3436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician