Provider Demographics
NPI:1427556554
Name:LARSON, CHARYSSE (DPT)
Entity Type:Individual
Prefix:
First Name:CHARYSSE
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:RYSSE
Other - Middle Name:
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2140 E ROSEMONTE DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024-2463
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5605 W EUGIE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1272
Practice Address - Country:US
Practice Address - Phone:602-865-2534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13048225100000X
2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics