Provider Demographics
NPI:1053934190
Name:LARSON, CASEY MARIE (LICSW)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:MARIE
Last Name:LARSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 1ST AVE SW STE 300W
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-3389
Mailing Address - Country:US
Mailing Address - Phone:507-722-1139
Mailing Address - Fax:888-682-9905
Practice Address - Street 1:421 1ST AVE SW STE 300W
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-3389
Practice Address - Country:US
Practice Address - Phone:507-722-1139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-23
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MN180541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health