Provider Demographics
NPI:1134252265
Name:LARSON, ASHLEY FABRE (MPT)
Entity type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:FABRE
Last Name:LARSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3529 WESTERVELT AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70820-5057
Mailing Address - Country:US
Mailing Address - Phone:225-756-0799
Mailing Address - Fax:
Practice Address - Street 1:3529 WESTERVELT AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70820-5057
Practice Address - Country:US
Practice Address - Phone:225-756-0799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA045222251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1314935Medicaid