Provider Demographics
NPI:1508462623
Name:LARSON, OLIVIA GRACE (PHD)
Entity Type:Individual
Prefix:DR
First Name:OLIVIA
Middle Name:GRACE
Last Name:LARSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6725 YORK AVE S APT 207
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-3220
Mailing Address - Country:US
Mailing Address - Phone:651-492-9740
Mailing Address - Fax:
Practice Address - Street 1:1 VETERANS DR
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-2309
Practice Address - Country:US
Practice Address - Phone:612-629-7247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-06
Last Update Date:2020-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6628103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical