Basic Information
| Provider Information | |||||||||
| NPI: | 1740226851 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LARSON | ||||||||
| OtherFirstName: | KAREN | ||||||||
| OtherMiddleName: | T | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3915 GOLDEN VALLEY ROAD | ||||||||
| Address2: | COURAGE CENTER | ||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635200354 | ||||||||
| FaxNumber: | 7635200355 | ||||||||
| Practice Location | |||||||||
| Address1: | 3915 GOLDEN VALLEY ROAD | ||||||||
| Address2: | COURAGE CENTER | ||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635200354 | ||||||||
| FaxNumber: | 7635200355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 07/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP0943 | MN | N | Behavioral Health & Social Service Providers | Psychologist | 103TP2701X | LP0943 | MN | N | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | 103TR0400X | LP0943 | MN | N | Behavioral Health & Social Service Providers | Psychologist | Rehabilitation | 103TC0700X | LP0943 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6236955 | 01 | UBH | OTHER | MA6552110 | 01 | SOUTH DAKOTA MA | OTHER | 963371008570 | 01 | PREFERRED ONE | OTHER | 6K899LA | 01 | BCBS MINNESOTA | OTHER | 035053200 | 05 | MN | MEDICAID | 6281912 | 01 | MEDICA | OTHER | 167670 | 01 | UCARE | OTHER | HP39217 | 01 | HEALTHPARTNERS | OTHER |