Provider Demographics
NPI:1174661581
Name:EXSTROM LARSEN, DENISE ANNE (PT)
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:ANNE
Last Name:EXSTROM LARSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3818 NORMAL BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506
Mailing Address - Country:US
Mailing Address - Phone:402-488-4282
Mailing Address - Fax:402-488-6157
Practice Address - Street 1:3818 NORMAL BOULEVARD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506
Practice Address - Country:US
Practice Address - Phone:402-488-4282
Practice Address - Fax:402-488-6157
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE661225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE39619OtherBCBS
NE650025850OtherRAIDROAD MEDICARE
NE10024956500Medicaid
NE39619OtherBCBS