Provider Demographics
NPI:1851680847
Name:LARSON, KELSEY ELISABETH
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:ELISABETH
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:ELISABETH
Other - Last Name:ROHLCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9500 EUCLID AVE
Mailing Address - Street 2:MAIL CODE A80
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0001
Mailing Address - Country:US
Mailing Address - Phone:216-315-0937
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:MAIL CODE A80
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:216-315-0937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.128235208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program