Provider Demographics
NPI:1144569625
Name:LARSON, THERESA (DPT, CSCS, SFMA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:DPT, CSCS, SFMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33080
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-2080
Mailing Address - Country:US
Mailing Address - Phone:877-854-1343
Mailing Address - Fax:
Practice Address - Street 1:3027 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-5002
Practice Address - Country:US
Practice Address - Phone:877-854-1343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-04
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 39650225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist