Provider Demographics
NPI:1497740088
Name:LARSEN, LARRY NELS (PT, ATC, STS)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:NELS
Last Name:LARSEN
Suffix:
Gender:M
Credentials:PT, ATC, STS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 IRVING PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4605
Mailing Address - Country:US
Mailing Address - Phone:318-425-5604
Mailing Address - Fax:318-222-8165
Practice Address - Street 1:1717 IRVING PL
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4605
Practice Address - Country:US
Practice Address - Phone:318-425-5604
Practice Address - Fax:318-222-8165
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0321225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1112143Medicaid
LA0321OtherPHYSICAL THERAPY LICENSE#
LA52161OtherBC/BS OF LA INDIVIDUAL #
LA00321OtherF A RICHARDS INSURANCE
LA09098OtherBC/BS OF LA GROUP #
LA220610OtherMETLIFE HEALTH CARE
LAPT0321OtherCLAIMS MANAGEMENT INC.
LA52161OtherBC/BS OF LA INDIVIDUAL #