Healthcare Provider Details

I. General information

NPI: 1336028372
Provider Name (Legal Business Name): LARAE MARIE LETEXIER LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2025
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 COTTONWOOD ST APT 103
GRAND FORKS ND
58201-4843
US

IV. Provider business mailing address

911 COTTONWOOD ST APT 103
GRAND FORKS ND
58201-4843
US

V. Phone/Fax

Practice location:
  • Phone: 218-773-6413
  • Fax:
Mailing address:
  • Phone: 218-773-6413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7019
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12271-123
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34859
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: