Provider Demographics
NPI:1821170077
Name:LARSON, THOMAS ERIC (PTA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:ERIC
Last Name:LARSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 S MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45327-1219
Mailing Address - Country:US
Mailing Address - Phone:937-855-2103
Mailing Address - Fax:
Practice Address - Street 1:4100 W 3RD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45428-9000
Practice Address - Country:US
Practice Address - Phone:937-268-6511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2224225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant