Provider Demographics
NPI:1508393505
Name:LARSEN, ANNIE ROSE (LMT, LR, BCTMB, MAT)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:ROSE
Last Name:LARSEN
Suffix:
Gender:F
Credentials:LMT, LR, BCTMB, MAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3222 28TH ST S STE A
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-5183
Mailing Address - Country:US
Mailing Address - Phone:701-232-4770
Mailing Address - Fax:701-237-3251
Practice Address - Street 1:3222 28TH ST S STE A
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-5183
Practice Address - Country:US
Practice Address - Phone:701-232-4770
Practice Address - Fax:701-237-3251
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1263225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty