Provider Demographics
NPI:1699016113
Name:JOME, LARAE M (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARAE
Middle Name:M
Last Name:JOME
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 1:6340 ITHACA LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-4146
Mailing Address - Country:US
Mailing Address - Phone:763-772-6272
Mailing Address - Fax:
Practice Address - Street 1:7026 E FISH LAKE RD
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-2832
Practice Address - Country:US
Practice Address - Phone:763-772-6272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015031103TC1900X
MNLP5850103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling