Provider Demographics
NPI:1447583513
Name:SPADE, LARRY GEORGE (PTA)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:GEORGE
Last Name:SPADE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5312 CYNTHIA LN
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2021
Mailing Address - Country:US
Mailing Address - Phone:937-432-6414
Mailing Address - Fax:
Practice Address - Street 1:3800 SUMMIT GLEN RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45449-3647
Practice Address - Country:US
Practice Address - Phone:937-436-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA04350225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant