Provider Demographics
NPI:1538482443
Name:LARSEN, GRAIG (PT, DPT)
Entity Type:Individual
Prefix:
First Name:GRAIG
Middle Name:
Last Name:LARSEN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL RD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-8809
Mailing Address - Country:US
Mailing Address - Phone:631-456-5512
Mailing Address - Fax:631-456-5514
Practice Address - Street 1:100 HOSPITAL RD
Practice Address - Street 2:SUITE 112
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-8809
Practice Address - Country:US
Practice Address - Phone:631-456-5512
Practice Address - Fax:631-456-5514
Is Sole Proprietor?:No
Enumeration Date:2010-03-05
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032030225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist