Provider Demographics
NPI:1801229646
Name:LARSON, RACHAEL MAJA
Entity Type:Individual
Prefix:MS
First Name:RACHAEL
Middle Name:MAJA
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 1:4788 PANORAMA DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-1239
Mailing Address - Country:US
Mailing Address - Phone:503-302-6036
Mailing Address - Fax:
Practice Address - Street 1:2211 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:LEMON GROVE
Practice Address - State:CA
Practice Address - Zip Code:91945-3616
Practice Address - Country:US
Practice Address - Phone:619-698-0903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPE 5080235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist