Healthcare Provider Details

I. General information

NPI: 1609005636
Provider Name (Legal Business Name): NAOMI NICOLE DORIOTT LARSON M.A., LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2009
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12918 63RD AVE N
MAPLE GROVE MN
55369-6001
US

IV. Provider business mailing address

12918 63RD AVE N
MAPLE GROVE MN
55369-6001
US

V. Phone/Fax

Practice location:
  • Phone: 763-210-9966
  • Fax:
Mailing address:
  • Phone: 763-210-9966
  • Fax: 715-377-0010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number619-226
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4609-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: