Provider Demographics
NPI:1194467597
Name:LARSON, RILEY C (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:C
Last Name:LARSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 CODY AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-4115
Mailing Address - Country:US
Mailing Address - Phone:307-747-7200
Mailing Address - Fax:
Practice Address - Street 1:919 CODY AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-4115
Practice Address - Country:US
Practice Address - Phone:307-747-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYSP-1144235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist