Provider Demographics
NPI:1689493603
Name:LARSEN, TESSA R (MS SLP)
Entity type:Individual
Prefix:
First Name:TESSA
Middle Name:R
Last Name:LARSEN
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 1ST ST E
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-5211
Mailing Address - Country:US
Mailing Address - Phone:701-300-0019
Mailing Address - Fax:
Practice Address - Street 1:221 UNIVERSITY AVE STE 203
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-5618
Practice Address - Country:US
Practice Address - Phone:701-580-8788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2774235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist