Provider Demographics
NPI:1265892210
Name:LARSEN, ELIZABETH (BS)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 LARKSPUR ST
Mailing Address - Street 2:
Mailing Address - City:PONDERAY
Mailing Address - State:ID
Mailing Address - Zip Code:83852-5011
Mailing Address - Country:US
Mailing Address - Phone:208-610-8652
Mailing Address - Fax:
Practice Address - Street 1:207 LARKSPUR ST
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-5011
Practice Address - Country:US
Practice Address - Phone:208-610-8652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist