Provider Demographics
NPI:1245580885
Name:LARSEN, ASHLEY MARIE
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MARIE
Last Name:LARSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-5557
Mailing Address - Country:US
Mailing Address - Phone:406-208-1938
Mailing Address - Fax:406-587-0898
Practice Address - Street 1:1707 OAK ST
Practice Address - Street 2:SUITE D
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-2125
Practice Address - Country:US
Practice Address - Phone:406-587-8446
Practice Address - Fax:406-587-0898
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC-1404225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist