Provider Demographics
NPI:1942866496
Name:LARSON, CARLY DELL (OT)
Entity Type:Individual
Prefix:MS
First Name:CARLY
Middle Name:DELL
Last Name:LARSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:DELL
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2812 W 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801-6202
Mailing Address - Country:US
Mailing Address - Phone:620-208-7878
Mailing Address - Fax:620-208-7000
Practice Address - Street 1:1102 SAINT MARYS RD
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:KS
Practice Address - Zip Code:66441-4196
Practice Address - Country:US
Practice Address - Phone:785-762-3350
Practice Address - Fax:785-762-3920
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-03569225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist