Provider Demographics
NPI:1003853326
Name:LARSON, BRENT H (PT)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:H
Last Name:LARSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7581 9TH ST N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-6626
Mailing Address - Country:US
Mailing Address - Phone:651-748-4338
Mailing Address - Fax:651-748-2892
Practice Address - Street 1:709 RIVARD ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:WI
Practice Address - Zip Code:54025-7382
Practice Address - Country:US
Practice Address - Phone:715-247-5735
Practice Address - Fax:715-247-5738
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN7714225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40462000Medicaid