Provider Demographics
NPI:1235439498
Name:LARSON, PATTI (PATTI LARSON)
Entity Type:Individual
Prefix:
First Name:PATTI
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:PATTI LARSON
Other - Prefix:
Other - First Name:PATTI
Other - Middle Name:
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PATTI LARSON PT, ATC
Mailing Address - Street 1:51 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:WILLOW LAKE
Mailing Address - State:SD
Mailing Address - Zip Code:57278-2331
Mailing Address - Country:US
Mailing Address - Phone:605-625-2592
Mailing Address - Fax:
Practice Address - Street 1:51 GRANT AVE
Practice Address - Street 2:
Practice Address - City:WILLOW LAKE
Practice Address - State:SD
Practice Address - Zip Code:57278-2331
Practice Address - Country:US
Practice Address - Phone:605-625-2592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1359174H00000X
SD0297174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator