Healthcare Provider Details

I. General information

NPI: 1932722592
Provider Name (Legal Business Name): LILY ROSE LARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2020
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E 78TH ST
BLOOMINGTON MN
55420-1400
US

IV. Provider business mailing address

5790 145TH CT NW
RAMSEY MN
55303-5684
US

V. Phone/Fax

Practice location:
  • Phone: 952-234-6860
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number305897
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: