Provider Demographics
NPI:1609005636
Name:DORIOTT LARSON, NAOMI NICOLE (MA, LPC)
Entity Type:Individual
Prefix:MISS
First Name:NAOMI
Middle Name:NICOLE
Last Name:DORIOTT LARSON
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12918 63RD AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-6001
Mailing Address - Country:US
Mailing Address - Phone:763-210-9966
Mailing Address - Fax:715-377-0010
Practice Address - Street 1:12918 63RD AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-6001
Practice Address - Country:US
Practice Address - Phone:763-210-9966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-12
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WI619-226101YP2500X
WI4609-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty