Healthcare Provider Details

I. General information

NPI: 1750127817
Provider Name (Legal Business Name): ANDREW LARSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LONDON RD
MARSHALL MN
56258-3070
US

IV. Provider business mailing address

301 E MAIN AVE
FERTILE MN
56540-4025
US

V. Phone/Fax

Practice location:
  • Phone: 507-537-2240
  • Fax:
Mailing address:
  • Phone: 218-536-0056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number528869
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1019021
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: