Provider Demographics
NPI:1588034136
Name:LARSON, ROBERT (PT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:LARSON
Suffix:
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 1:7455 MORGAN RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-3956
Mailing Address - Country:US
Mailing Address - Phone:315-451-6767
Mailing Address - Fax:315-451-0569
Practice Address - Street 1:7455 MORGAN RD
Practice Address - Street 2:SUITE 2
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-3956
Practice Address - Country:US
Practice Address - Phone:315-451-6767
Practice Address - Fax:315-451-0569
Is Sole Proprietor?:No
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039487225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist