Provider Demographics
NPI:1093982662
Name:LARSON, JOHANNA E (LAC)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:E
Last Name:LARSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8701 SHOAL CREEK BLVD STE 302
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-6809
Mailing Address - Country:US
Mailing Address - Phone:512-731-4995
Mailing Address - Fax:
Practice Address - Street 1:8701 SHOAL CREEK BLVD STE 302
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-6809
Practice Address - Country:US
Practice Address - Phone:512-731-4995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist