Provider Demographics
NPI:1346801586
Name:LARSON-PROFFITT, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:LARSON-PROFFITT
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 1:5764 N. ORANGE BLOSSOM TRL
Mailing Address - Street 2:PMB 96747
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810
Mailing Address - Country:US
Mailing Address - Phone:570-575-7359
Mailing Address - Fax:
Practice Address - Street 1:2216 LESTER DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-2607
Practice Address - Country:US
Practice Address - Phone:505-296-4808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0002629225X00000X
NMOT4723225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist