Provider Demographics
NPI:1659310845
Name:LARSON, SANDRA K (PT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:K
Last Name:LARSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-1120
Mailing Address - Country:US
Mailing Address - Phone:563-382-4770
Mailing Address - Fax:563-382-4785
Practice Address - Street 1:516 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-2720
Practice Address - Country:US
Practice Address - Phone:563-382-4770
Practice Address - Fax:563-382-4785
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA035652251G0304X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Not Answered2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA34900OtherBLUE CROSS BLUE SHEILD
IAF245962OtherMIDLANDS CHOICE
IATN0100OtherJOHN DEERE
IAI10016Medicare ID - Type Unspecified