Provider Demographics
NPI:1225217060
Name:LARSEN, LAURA MARIE (COTAL)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:MARIE
Last Name:LARSEN
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4675 DALE ST N
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126
Mailing Address - Country:US
Mailing Address - Phone:651-484-9099
Mailing Address - Fax:
Practice Address - Street 1:119 OWENS ST N
Practice Address - Street 2:GOOD SAMARITAN SYNERTX REHABILITATION
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082
Practice Address - Country:US
Practice Address - Phone:651-439-7180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN200519224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant