Provider Demographics
NPI:1265772552
Name:LARSEN, RONALD WAYNE (CRC)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:WAYNE
Last Name:LARSEN
Suffix:
Gender:M
Credentials:CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8609 LYNDALE AVE S
Mailing Address - Street 2:101K
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-2754
Mailing Address - Country:US
Mailing Address - Phone:952-888-2424
Mailing Address - Fax:952-888-6729
Practice Address - Street 1:8609 LYNDALE AVE S
Practice Address - Street 2:101K
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-2754
Practice Address - Country:US
Practice Address - Phone:952-888-2424
Practice Address - Fax:952-888-6729
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-22
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNQRC#290101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor