Provider Demographics
NPI:1538202890
Name:LARSON, CAROLE (NICKEY) GALUSH (PSYD LP LMFT LADC)
Entity type:Individual
Prefix:DR
First Name:CAROLE (NICKEY)
Middle Name:GALUSH
Last Name:LARSON
Suffix:
Gender:F
Credentials:PSYD LP LMFT LADC
Other - Prefix:DR
Other - First Name:NICKEY
Other - Middle Name:G
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD LP LMFT LADC
Mailing Address - Street 1:7400 METRO BLVD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-2316
Mailing Address - Country:US
Mailing Address - Phone:952-929-8432
Mailing Address - Fax:952-929-8432
Practice Address - Street 1:7400 METRO BLVD
Practice Address - Street 2:SUITE 215
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2316
Practice Address - Country:US
Practice Address - Phone:952-929-8432
Practice Address - Fax:952-929-8432
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300756101YA0400X
MN1810103T00000X, 103T00000X
MN466106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
122275OtherHEALTH PARTNERS FINANCIAL
46715LAOtherBCBS INDIVIDUAL
MN563350800Medicaid
46714LAOtherBCBS GROUP
MN680002129Medicare ID - Type Unspecified