Provider Demographics
NPI:1740352921
Name:LARSON, JOAN SAGEDAHL (MSSA LICSW)
Entity type:Individual
Prefix:MS
First Name:JOAN
Middle Name:SAGEDAHL
Last Name:LARSON
Suffix:
Gender:F
Credentials:MSSA LICSW
Other - Prefix:MS
Other - First Name:JOAN
Other - Middle Name:ELEANOR
Other - Last Name:SAGEDAHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSSA LICSW
Mailing Address - Street 1:1280 NORTH BIRCH LAKE BLVD
Mailing Address - Street 2:WHITE BEAR LAKE AREA COMMUNITY COUNSELING CENTER
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-6708
Mailing Address - Country:US
Mailing Address - Phone:651-429-8544
Mailing Address - Fax:651-407-5301
Practice Address - Street 1:1280 NORTH BIRCH LAKE BLVD
Practice Address - Street 2:WHITE BEAR LAKE AREA COMMUNITY COUNSELING CENTER
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-6708
Practice Address - Country:US
Practice Address - Phone:651-429-8544
Practice Address - Fax:651-407-5301
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN064201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN104651OtherUCARE MINNESOTA
MN40115OtherBEHAVIORAL HEALTCARE PROV
MN5H417LAOtherBLUE CROSS BLUE SHIELD