Provider Demographics
NPI:1972005247
Name:LARSEN, TREVOR J
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:J
Last Name:LARSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 FALMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02632-2939
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 FALMOUTH RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02632-2939
Practice Address - Country:US
Practice Address - Phone:508-775-0060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-02
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA235122251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty