Provider Demographics
NPI:1316231053
Name:LARSON, CAROLYN MICHELLE (SLP)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:MICHELLE
Last Name:LARSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2243 N LISTER AVE APT 302
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-6395
Mailing Address - Country:US
Mailing Address - Phone:309-310-5961
Mailing Address - Fax:
Practice Address - Street 1:2243 N LISTER AVE
Practice Address - Street 2:APT 302
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-9016
Practice Address - Country:US
Practice Address - Phone:309-310-5961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-29
Last Update Date:2011-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146008841235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist