Provider Demographics
NPI:1003914359
Name:LARSON, GLADYS ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:GLADYS
Middle Name:ELIZABETH
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GLADYS
Other - Middle Name:ELIZABETH
Other - Last Name:JACOBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS OF AUDIOLOGY
Mailing Address - Street 1:497 WEST LOTT
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:WY
Mailing Address - Zip Code:82834-1609
Mailing Address - Country:US
Mailing Address - Phone:307-684-3139
Mailing Address - Fax:307-684-5384
Practice Address - Street 1:497 WEST LOTT
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:WY
Practice Address - Zip Code:82834-1609
Practice Address - Country:US
Practice Address - Phone:307-684-3139
Practice Address - Fax:307-684-5384
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYA910231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist