Provider Demographics
NPI:1437460334
Name:LARSON, MIRANDA CATHLEEN (BCTMB, LMT)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:CATHLEEN
Last Name:LARSON
Suffix:
Gender:F
Credentials:BCTMB, LMT
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:CATHLEEN
Other - Last Name:HENDRICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:112 UNIVERSITY DR N
Mailing Address - Street 2:STE 316
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4661
Mailing Address - Country:US
Mailing Address - Phone:218-289-0276
Mailing Address - Fax:
Practice Address - Street 1:112 UNIVERSITY DR N
Practice Address - Street 2:STE 316
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4661
Practice Address - Country:US
Practice Address - Phone:218-289-0276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1539225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist