Provider Demographics
NPI:1255424339
Name:LARSON, LINDA L (LCSW)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:L
Last Name:LARSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8056 149TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRENORA
Mailing Address - State:ND
Mailing Address - Zip Code:58845
Mailing Address - Country:US
Mailing Address - Phone:701-694-3692
Mailing Address - Fax:
Practice Address - Street 1:316 2ND AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:55880
Practice Address - Country:US
Practice Address - Phone:701-774-4600
Practice Address - Fax:701-774-4620
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND33011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND021190OtherBCBS
ND54516Medicaid
N21190Medicare ID - Type Unspecified