Provider Demographics
NPI:1043251267
Name:LARSON, JUDITH A (PT)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:LARSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1970 NAVAJO ST
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-8890
Mailing Address - Country:US
Mailing Address - Phone:715-420-1593
Mailing Address - Fax:
Practice Address - Street 1:1970 NAVAJO ST
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-8890
Practice Address - Country:US
Practice Address - Phone:715-420-1593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2013-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1711225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100012286Medicaid
WI40005600Medicaid
WI525589Medicare Oscar/Certification