Provider Demographics
NPI:1720058530
Name:LARSON, JULIE MICHELLE (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:MICHELLE
Last Name:LARSON
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11481 SW HALL BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8403
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-443-1402
Practice Address - Street 1:12550 SE 93RD AVE
Practice Address - Street 2:STE 265
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9786
Practice Address - Country:US
Practice Address - Phone:503-659-9155
Practice Address - Fax:503-659-7336
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4769225100000X
MA40QA00746800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269615Medicaid
OR130886Medicare PIN
OR130887Medicare PIN