Provider Demographics
NPI:1972736155
Name:LARSON, KELLY NICHOLE (LMFT)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:NICHOLE
Last Name:LARSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-5842
Mailing Address - Country:US
Mailing Address - Phone:651-363-0821
Mailing Address - Fax:
Practice Address - Street 1:310 E 38TH ST STE 320
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55409-1338
Practice Address - Country:US
Practice Address - Phone:612-243-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-03
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1895106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist