Provider Demographics
NPI:1083952022
Name:LARSON, MARY LOUISE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 BAKKEN RD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-7625
Mailing Address - Country:US
Mailing Address - Phone:715-410-7202
Mailing Address - Fax:
Practice Address - Street 1:425 DAVIS ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:WI
Practice Address - Zip Code:54015-9615
Practice Address - Country:US
Practice Address - Phone:715-796-2218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-25
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1204-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist