Provider Demographics
NPI:1134250590
Name:LARSON, KRISTA M (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:M
Last Name:LARSON
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-5190
Mailing Address - Country:US
Mailing Address - Phone:507-301-1982
Mailing Address - Fax:507-786-3786
Practice Address - Street 1:402 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-5190
Practice Address - Country:US
Practice Address - Phone:507-301-1982
Practice Address - Fax:507-786-3786
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN143481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN787623800Medicaid
MN800001910Medicare UPIN