Provider Demographics
NPI:1093969685
Name:LARSON, ROXANN LEE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ROXANN
Middle Name:LEE
Last Name:LARSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39874 240TH ST
Mailing Address - Street 2:
Mailing Address - City:LETCHER
Mailing Address - State:SD
Mailing Address - Zip Code:57359-6203
Mailing Address - Country:US
Mailing Address - Phone:605-248-2525
Mailing Address - Fax:605-248-1400
Practice Address - Street 1:39874 240TH ST
Practice Address - Street 2:
Practice Address - City:LETCHER
Practice Address - State:SD
Practice Address - Zip Code:57359-6203
Practice Address - Country:US
Practice Address - Phone:605-248-2525
Practice Address - Fax:605-248-1400
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-09
Last Update Date:2008-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD12069370235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist