Provider Demographics
NPI:1235273780
Name:LARSON, ANTOINETTE MARIE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:ANTOINETTE
Middle Name:MARIE
Last Name:LARSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:384 CHATEAUGAY LN
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2849
Mailing Address - Country:US
Mailing Address - Phone:314-485-1180
Mailing Address - Fax:314-485-1160
Practice Address - Street 1:384 CHATEAUGAY LN
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-2849
Practice Address - Country:US
Practice Address - Phone:314-485-1180
Practice Address - Fax:314-485-1160
Is Sole Proprietor?:No
Enumeration Date:2007-02-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000915225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO473528941Medicaid