Provider Demographics
NPI:1114324720
Name:LARSON, TERESA (DIETITIAN)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 W COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-1319
Mailing Address - Country:US
Mailing Address - Phone:720-391-6605
Mailing Address - Fax:
Practice Address - Street 1:831 W COLORADO AVE
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-1319
Practice Address - Country:US
Practice Address - Phone:720-391-6605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist