MEDICARE: DR. LARAINE PATRICIA KURISKO PH.D., LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	LP4466	MN

General Provider Information

NPI Number	:	1104911676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARAINE PATRICIA KURISKO PH.D., LP

Provider Business Mailing Address
First Line	:	18664 OVERLAND TRAIL
Second Line	:
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55347-4186
Country	:	US
Telephone Number	:	952-974-3764
Fax Number	:

Provider Business Practice Location Address
First Line	:	4005 WEST 65TH STREET
Second Line	:	SUITE 104
City	:	EDINA
State	:	MN
Zip	:	55435
Country	:	US
Telephone Number	:	952-926-2424
Fax Number	:	952-926-3454

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	07/08/2007

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