Healthcare Provider Details

I. General information

NPI: 1184341877
Provider Name (Legal Business Name): GWYNEVERE ABIGAIL LARSON-MCCLUSKEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 HERITAGE DR STE A
NORTHFIELD MN
55057-3227
US

IV. Provider business mailing address

1403 HERITAGE DR
NORTHFIELD MN
55057-3226
US

V. Phone/Fax

Practice location:
  • Phone: 763-200-4374
  • Fax: 612-662-8779
Mailing address:
  • Phone: 763-200-4374
  • Fax: 612-662-8779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: