Provider Demographics
NPI:1417203134
Name:LARSEN, JULIE ELIZABETH (RD, CD)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ELIZABETH
Last Name:LARSEN
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:MS
Other - First Name:JULIE
Other - Middle Name:ELIZABETH
Other - Last Name:REAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:S2845 WHITE EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-9064
Mailing Address - Country:US
Mailing Address - Phone:608-335-1240
Mailing Address - Fax:
Practice Address - Street 1:S2845 WHITE EAGLE RD
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-9064
Practice Address - Country:US
Practice Address - Phone:608-335-1240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2515133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered