Provider Demographics
NPI:1780003160
Name:LARSON, KIMBERLY (PTA)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30980 SCOTT PARK RD TRLR 72
Mailing Address - Street 2:
Mailing Address - City:LONG GROVE
Mailing Address - State:IA
Mailing Address - Zip Code:52756-9641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30980 SCOTT PARK RD TRLR 72
Practice Address - Street 2:
Practice Address - City:LONG GROVE
Practice Address - State:IA
Practice Address - Zip Code:52756-9641
Practice Address - Country:US
Practice Address - Phone:563-210-1308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-14
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01072225200000X
IL160004520225200000X
MO2014009194225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant