Provider Demographics
NPI:1639321763
Name:LARSON, NICOLE (OTR)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 W BRAXTON DR
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-3318
Mailing Address - Country:US
Mailing Address - Phone:605-351-2985
Mailing Address - Fax:
Practice Address - Street 1:1316 W BRAXTON DR
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-3318
Practice Address - Country:US
Practice Address - Phone:605-351-2985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0498225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist