Provider Demographics
NPI:1760156376
Name:LARSON, KATIE MARIE (LPCCN)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MARIE
Last Name:LARSON
Suffix:
Gender:F
Credentials:LPCCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 HIGHWAY 12 E STE 2
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-5811
Mailing Address - Country:US
Mailing Address - Phone:320-214-9692
Mailing Address - Fax:320-214-9924
Practice Address - Street 1:2320 HIGHWAY 12 E STE 2
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-5811
Practice Address - Country:US
Practice Address - Phone:320-214-9692
Practice Address - Fax:320-214-9924
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2927103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical