Provider Demographics
NPI:1679118921
Name:LARSON, MEREDITH
Entity type:Individual
Prefix:MISS
First Name:MEREDITH
Middle Name:
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 1:1164 101ST AVE NE UNIT C
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-3863
Mailing Address - Country:US
Mailing Address - Phone:763-807-5615
Mailing Address - Fax:
Practice Address - Street 1:5301 KYLER AVE NE STE 101
Practice Address - Street 2:
Practice Address - City:ALBERTVILLE
Practice Address - State:MN
Practice Address - Zip Code:55301-4718
Practice Address - Country:US
Practice Address - Phone:763-220-2312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty