Provider Demographics
NPI:1841805868
Name:LARSON, ROMY T
Entity Type:Individual
Prefix:
First Name:ROMY
Middle Name:T
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 1:5580 BARTON RD UNIT 302
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-3839
Mailing Address - Country:US
Mailing Address - Phone:440-503-0091
Mailing Address - Fax:
Practice Address - Street 1:5580 BARTON RD UNIT 302
Practice Address - Street 2:
Practice Address - City:NORTH OLMSTED
Practice Address - State:OH
Practice Address - Zip Code:44070-3839
Practice Address - Country:US
Practice Address - Phone:440-503-0091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0390174Medicaid