=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538527262
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LARSON INDIVIDUAL AND FAMILY THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2016
-----------------------------------------------------
Last Update Date | 09/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5200 WILLSON RD STE 320
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55424-1332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-405-6093
-----------------------------------------------------
Fax | 952-405-6093
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5200 WILLSON RD STE 320
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55424-1332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-405-6093
-----------------------------------------------------
Fax | 952-405-6093
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | ERIC CHRISTOPHER LARSON
-----------------------------------------------------
Credential | MSW, LICSWL
-----------------------------------------------------
Telephone | 952-405-6093
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 19647
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------