Provider Demographics
NPI:1235108507
Name:LARSON, AMY ELIZABETH (ATC)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:ELIZABETH
Last Name:LARSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13301 W PINE GROVE CT
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-8610
Mailing Address - Country:US
Mailing Address - Phone:708-301-0309
Mailing Address - Fax:
Practice Address - Street 1:30 N BRAINARD ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-4607
Practice Address - Country:US
Practice Address - Phone:630-637-5533
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer