Provider Demographics
NPI:1912329301
Name:LARSON, DAVID (LADC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1786
Mailing Address - Country:US
Mailing Address - Phone:651-379-1718
Mailing Address - Fax:651-379-1738
Practice Address - Street 1:13603 80TH CIR N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-8961
Practice Address - Country:US
Practice Address - Phone:763-416-1489
Practice Address - Fax:763-416-3957
Is Sole Proprietor?:No
Enumeration Date:2014-01-20
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300922101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)