Provider Demographics
NPI:1558837039
Name:LARSON, KATLIN LOUISE
Entity Type:Individual
Prefix:
First Name:KATLIN
Middle Name:LOUISE
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 1:825 34TH AVE E APT 101
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-2917
Mailing Address - Country:US
Mailing Address - Phone:320-808-8456
Mailing Address - Fax:
Practice Address - Street 1:7010 HIGHWAY 7
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-4223
Practice Address - Country:US
Practice Address - Phone:951-814-0207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician