Provider Demographics
NPI:1649038506
Name:LARSON, DIANE MARY
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARY
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 SHORELINE DR STE 102
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-9591
Mailing Address - Country:US
Mailing Address - Phone:952-314-7533
Mailing Address - Fax:
Practice Address - Street 1:3701 SHORELINE DR STE 102
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-9591
Practice Address - Country:US
Practice Address - Phone:952-314-7533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN02877101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty