Provider Demographics
NPI:1376717264
Name:LARSON, KARLA MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:KARLA
Middle Name:MARIE
Last Name:LARSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P4803 COUNTY ROAD Z
Mailing Address - Street 2:
Mailing Address - City:BIRNAMWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:54414-9414
Mailing Address - Country:US
Mailing Address - Phone:715-449-3261
Mailing Address - Fax:
Practice Address - Street 1:729 PARK ST
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2745
Practice Address - Country:US
Practice Address - Phone:715-623-2356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1952-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1952-024OtherWI PROFESSIONAL PT LICENSE
WI40020100Medicaid