MEDICARE: DR. LARAE M JOME PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	015031	NY
2	103TC1900X	Counseling Psychologist	LP5850	MN

General Provider Information

NPI Number	:	1699016113
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARAE M JOME PH.D.

Provider Business Mailing Address
First Line	:	6340 ITHACA LN N
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55311-4146
Country	:	US
Telephone Number	:	763-772-6272
Fax Number	:

Provider Business Practice Location Address
First Line	:	7026 E FISH LAKE RD
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55311-2832
Country	:	US
Telephone Number	:	763-772-6272
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2013
Last Update Date	:	06/07/2016

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