Provider Demographics
NPI:1073223814
Name:LARSEN, MARTINA CHANTELLE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARTINA
Middle Name:CHANTELLE
Last Name:LARSEN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 341
Mailing Address - Street 2:
Mailing Address - City:NEOLA
Mailing Address - State:UT
Mailing Address - Zip Code:84053-0341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:826 S 1500 E
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:UT
Practice Address - Zip Code:84078-8609
Practice Address - Country:US
Practice Address - Phone:435-781-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9433177-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist