Provider Demographics
NPI:1508643768
Name:LARSON, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 BERRY WAY
Mailing Address - Street 2:
Mailing Address - City:SCHERTZ
Mailing Address - State:TX
Mailing Address - Zip Code:78154-5403
Mailing Address - Country:US
Mailing Address - Phone:307-274-1179
Mailing Address - Fax:
Practice Address - Street 1:816 EVERYDAY WAY
Practice Address - Street 2:
Practice Address - City:CIBOLO
Practice Address - State:TX
Practice Address - Zip Code:78108-4080
Practice Address - Country:US
Practice Address - Phone:210-538-3812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118964225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation