Provider Demographics
NPI:1174972715
Name:LARSON, ANNETTE MARIE (MA, LPC, LADC)
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:MARIE
Last Name:LARSON
Suffix:
Gender:F
Credentials:MA, LPC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3328 92ND DR NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-6851
Mailing Address - Country:US
Mailing Address - Phone:763-444-1321
Mailing Address - Fax:763-785-8111
Practice Address - Street 1:199 COON RAPIDS BLVD NW
Practice Address - Street 2:SUITE 310
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5831
Practice Address - Country:US
Practice Address - Phone:763-785-8111
Practice Address - Fax:763-785-8111
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-05
Last Update Date:2016-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303923101YA0400X
MN01859101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01859OtherMINNESOTA BOARD OF BEHAVIORAL HEALTH AND THERAPY,LICENSED PROFESSIONAL COUNSELOR
MN7078OtherMINNESOTA CERTIFICATION BOARD, ALCOHOL AND DRUG COUNSELOR-MINNESOTA
MN303923OtherMINNESOTA BOARD OF BEHAVIORAL HEALTH AND THERAPY, ALCOHOL AND DRUG COUNSELOR