Provider Demographics
NPI:1265985469
Name:LARSEN, ATHENA
Entity type:Individual
Prefix:
First Name:ATHENA
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 140TH ST S STE 700
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-4549
Mailing Address - Country:US
Mailing Address - Phone:253-531-5645
Mailing Address - Fax:253-536-3467
Practice Address - Street 1:223 140TH ST S STE 700
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-4549
Practice Address - Country:US
Practice Address - Phone:253-531-5645
Practice Address - Fax:253-536-3467
Is Sole Proprietor?:No
Enumeration Date:2016-07-25
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPU 60677876225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist