Healthcare Provider Details

I. General information

NPI: 1306984497
Provider Name (Legal Business Name): CLAUDETTE M LARSON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CLAUDETTE M CARLSON-LARSON LICSW

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 09/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 ATLANTIC AVE
BENSON MN
56215
US

IV. Provider business mailing address

640 ATLANTIC AVENUE
BENSON MN
56215
US

V. Phone/Fax

Practice location:
  • Phone: 320-843-3454
  • Fax:
Mailing address:
  • Phone: 320-843-3454
  • Fax: 320-843-4692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16765
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number16765
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: