Provider Demographics
NPI:1558430488
Name:LARSON, ANDREW III (PT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:LARSON
Suffix:III
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2905 WARE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-6592
Mailing Address - Country:US
Mailing Address - Phone:815-229-1412
Mailing Address - Fax:815-623-9931
Practice Address - Street 1:4675 BLUESTEM RD
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-7788
Practice Address - Country:US
Practice Address - Phone:815-623-9930
Practice Address - Fax:815-623-9931
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist