Provider Demographics
NPI:1689102550
Name:LARSON, EMILY JEAN
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:JEAN
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 S MONACO PKWY APT A
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80224-2064
Mailing Address - Country:US
Mailing Address - Phone:1574-220-7812
Mailing Address - Fax:
Practice Address - Street 1:21013 E JEFFERSON CIR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80013-7414
Practice Address - Country:US
Practice Address - Phone:720-353-8939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2017-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0002807235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO235Z00000XMedicaid