Healthcare Provider Details

I. General information

NPI: 1790658250
Provider Name (Legal Business Name): MRS. KELLI ANNE LARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2025
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WILSON AVE RM 330
MENOMONIE WI
54751-2746
US

IV. Provider business mailing address

800 WILSON AVE RM 330
MENOMONIE WI
54751-2746
US

V. Phone/Fax

Practice location:
  • Phone: 715-256-7166
  • Fax: 888-427-8048
Mailing address:
  • Phone: 715-256-7166
  • Fax: 888-427-8048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8709-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: