Provider Demographics
NPI:1841231065
Name:LARSON, ROGER A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:A
Last Name:LARSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1237 W DIVIDE AVE
Mailing Address - Street 2:STE 5
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1208
Mailing Address - Country:US
Mailing Address - Phone:701-328-8883
Mailing Address - Fax:701-328-8900
Practice Address - Street 1:1237 W DIVIDE AVE
Practice Address - Street 2:STE 5
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1208
Practice Address - Country:US
Practice Address - Phone:701-328-8883
Practice Address - Fax:701-328-8900
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND219103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
004479OtherBCBS OF ND PIN
R02144Medicare UPIN
N4479Medicare ID - Type Unspecified