Provider Demographics
NPI:1346906534
Name:LARSON, CALLIE S
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:S
Last Name:LARSON
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 1:17 PONKA RD
Mailing Address - Street 2:
Mailing Address - City:ESTANCIA
Mailing Address - State:NM
Mailing Address - Zip Code:87016-6758
Mailing Address - Country:US
Mailing Address - Phone:505-440-6297
Mailing Address - Fax:
Practice Address - Street 1:1815 WELLS ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88003-1304
Practice Address - Country:US
Practice Address - Phone:505-440-6297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-11
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NM2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program