Provider Demographics
NPI:1528594603
Name:LARSEN, JOANNA (MSED)
Entity Type:Individual
Prefix:MS
First Name:JOANNA
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6260 108TH ST
Mailing Address - Street 2:APT 6C
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1356
Mailing Address - Country:US
Mailing Address - Phone:631-793-7241
Mailing Address - Fax:
Practice Address - Street 1:6260 108TH ST
Practice Address - Street 2:APT 6C
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1356
Practice Address - Country:US
Practice Address - Phone:631-793-7241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1203089174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist