Provider Demographics
NPI:1033395322
Name:LARSON, BROOKSIE K
Entity Type:Individual
Prefix:MS
First Name:BROOKSIE
Middle Name:K
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:BROOKSIE
Other - Middle Name:K
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MPT
Mailing Address - Street 1:433 ELM ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2650
Mailing Address - Country:US
Mailing Address - Phone:509-758-5647
Mailing Address - Fax:509-758-5648
Practice Address - Street 1:433 ELM ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2650
Practice Address - Country:US
Practice Address - Phone:509-758-5647
Practice Address - Fax:509-758-5648
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008466225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8379778Medicaid
WA8379778Medicaid