Provider Demographics
NPI:1366505851
Name:LARSON, KRYSTYNA (PT, CLT)
Entity Type:Individual
Prefix:MS
First Name:KRYSTYNA
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:PT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 BLUEBIRD AVE
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-4302
Mailing Address - Country:US
Mailing Address - Phone:219-662-6318
Mailing Address - Fax:
Practice Address - Street 1:3900 W 95TH ST
Practice Address - Street 2:SUITE 7
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-1922
Practice Address - Country:US
Practice Address - Phone:708-423-7900
Practice Address - Fax:708-423-7999
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05002424A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00387674OtherRAILROAD MEDICARE
ILK36313Medicare ID - Type Unspecified
IN247620CMedicare ID - Type Unspecified