Provider Demographics
NPI:1972811735
Name:LARSEN, AMY M (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:LARSEN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98303 E BROOKLYN DR
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99338-7425
Mailing Address - Country:US
Mailing Address - Phone:509-628-2471
Mailing Address - Fax:
Practice Address - Street 1:723 MEMORIAL ST
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-1524
Practice Address - Country:US
Practice Address - Phone:509-786-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00004377235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist