Healthcare Provider Details

I. General information

NPI: 1699016113
Provider Name (Legal Business Name): LARAE M JOME PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2013
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7026 E FISH LAKE RD
MAPLE GROVE MN
55311-2832
US

IV. Provider business mailing address

6340 ITHACA LN N
MAPLE GROVE MN
55311-4146
US

V. Phone/Fax

Practice location:
  • Phone: 763-772-6272
  • Fax:
Mailing address:
  • Phone: 763-772-6272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number015031
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLP5850
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: