Provider Demographics
NPI:1083842736
Name:LARSON, DANIELLE M (DPT)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:M
Last Name:LARSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1439 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-9024
Mailing Address - Country:US
Mailing Address - Phone:919-557-2111
Mailing Address - Fax:919-557-5543
Practice Address - Street 1:1439 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-9024
Practice Address - Country:US
Practice Address - Phone:919-557-2111
Practice Address - Fax:919-557-5543
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12222225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7212635Medicaid
NC7212635Medicaid