Provider Demographics
NPI:1790082733
Name:LARSON, AMBER ELISE (LMP)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:ELISE
Last Name:LARSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440
Mailing Address - Country:UM
Mailing Address - Phone:253-630-6768
Mailing Address - Fax:253-630-6639
Practice Address - Street 1:32030 23RD AVE S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6031
Practice Address - Country:US
Practice Address - Phone:253-946-4852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-25
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60160203225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist