Healthcare Provider Details

I. General information

NPI: 1659170090
Provider Name (Legal Business Name): NICHOLAS LARSEN MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 34TH AVE E
ALEXANDRIA MN
56308-2599
US

IV. Provider business mailing address

702 34TH AVE E
ALEXANDRIA MN
56308-2599
US

V. Phone/Fax

Practice location:
  • Phone: 320-762-2400
  • Fax:
Mailing address:
  • Phone: 320-762-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4988
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: