Provider Demographics
NPI:1447756549
Name:LARSEN, CAROLYN LEA (PT)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:LEA
Last Name:LARSEN
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 1:2710 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-3701
Mailing Address - Country:US
Mailing Address - Phone:605-328-5900
Mailing Address - Fax:605-328-5963
Practice Address - Street 1:2710 W 12TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-3701
Practice Address - Country:US
Practice Address - Phone:605-328-5900
Practice Address - Fax:605-328-5963
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0488225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist