Provider Demographics
NPI:1639648082
Name:LARSON, BRANDON (PTA)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4603 COUNTY ROAD F
Mailing Address - Street 2:
Mailing Address - City:BLUE MOUNDS
Mailing Address - State:WI
Mailing Address - Zip Code:53517-9606
Mailing Address - Country:US
Mailing Address - Phone:608-963-3401
Mailing Address - Fax:
Practice Address - Street 1:501 S WINSTED ST
Practice Address - Street 2:
Practice Address - City:SPRING GREEN
Practice Address - State:WI
Practice Address - Zip Code:53588-9435
Practice Address - Country:US
Practice Address - Phone:608-588-0208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2795-192251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics