Provider Demographics
NPI:1578757431
Name:LARSON, RHODA M (LMT PTA)
Entity Type:Individual
Prefix:
First Name:RHODA
Middle Name:M
Last Name:LARSON
Suffix:
Gender:F
Credentials:LMT PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9407 W MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-4154
Mailing Address - Country:US
Mailing Address - Phone:414-940-6820
Mailing Address - Fax:
Practice Address - Street 1:12065 W JANESVILLE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-2368
Practice Address - Country:US
Practice Address - Phone:414-940-6820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1298-019225200000X
WI2135-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant