Healthcare Provider Details

I. General information

NPI: 1205588753
Provider Name (Legal Business Name): TRACY LARSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2022
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1527 NORTHWAY DR
SAINT CLOUD MN
56303-1221
US

IV. Provider business mailing address

10916 90TH AVE
MILACA MN
56353-3886
US

V. Phone/Fax

Practice location:
  • Phone: 320-650-3082
  • Fax:
Mailing address:
  • Phone: 320-761-6540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: