Provider Demographics
NPI:1811050248
Name:LARSEN, ANDREA SUSAN (PHD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:SUSAN
Last Name:LARSEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 OAK GROVE SUITE #230
Mailing Address - Street 2:LORING PARK OFFICE BUILDING
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-3253
Mailing Address - Country:US
Mailing Address - Phone:612-870-0230
Mailing Address - Fax:612-872-9170
Practice Address - Street 1:430 OAK GROVE SUITE #230
Practice Address - Street 2:LORING PARK OFFICE BUILDING
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-3253
Practice Address - Country:US
Practice Address - Phone:612-870-0230
Practice Address - Fax:612-872-9170
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1082103T00000X
MN0120103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
59681LAOtherBC