Provider Demographics
NPI:1508801325
Name:LARSEN, ROXANNA LEIGH (ATC)
Entity Type:Individual
Prefix:MRS
First Name:ROXANNA
Middle Name:LEIGH
Last Name:LARSEN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1761 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-8841
Mailing Address - Country:US
Mailing Address - Phone:570-387-5121
Mailing Address - Fax:
Practice Address - Street 1:400 E 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1301
Practice Address - Country:US
Practice Address - Phone:570-389-4668
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer