Basic Information
| Provider Information | |||||||||
| NPI: | 1306984497 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | CLAUDETTE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARLSON-LARSON | ||||||||
| OtherFirstName: | CLAUDETTE | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LICSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 640 ATLANTIC AVENUE | ||||||||
| Address2: | |||||||||
| City: | BENSON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3208433454 | ||||||||
| FaxNumber: | 3208434692 | ||||||||
| Practice Location | |||||||||
| Address1: | 640 ATLANTIC AVE | ||||||||
| Address2: | |||||||||
| City: | BENSON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3208433454 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 09/13/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 16765 | MN | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 16765 | MN | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 411910086 | 01 | MN | CORP HEALTH | OTHER | 600074381 | 01 | MN | MAGELLAN | OTHER | 1050870 | 01 | MN | BHP PREFERRED ONE | OTHER | 046D1CA | 01 | MN | BCBS | OTHER | 76660100 | 05 | MN | MEDICAID | HP78786 | 01 | MN | HEALTH PARTNERS | OTHER | 152193 | 01 | MN | UCARE | OTHER | 6984497 | 01 | MN | UBH | OTHER |