Provider Demographics
NPI:1144426164
Name:LARSSON, BENGT GOSTA (MS, PT)
Entity Type:Individual
Prefix:
First Name:BENGT
Middle Name:GOSTA
Last Name:LARSSON
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 PHILADELPHIA ST
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3902
Mailing Address - Country:US
Mailing Address - Phone:724-463-7478
Mailing Address - Fax:724-463-0931
Practice Address - Street 1:2605 EGYPT RD
Practice Address - Street 2:SUITE 104
Practice Address - City:TROOPER
Practice Address - State:PA
Practice Address - Zip Code:19403-2317
Practice Address - Country:US
Practice Address - Phone:610-666-1702
Practice Address - Fax:610-666-1726
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT017643225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA396749Medicare ID - Type UnspecifiedMEDICARE