Provider Demographics
NPI:1780954552
Name:LARSEN, DONALD LEE (COTA/L, RN)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:LEE
Last Name:LARSEN
Suffix:
Gender:M
Credentials:COTA/L, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 VICTORIA LAKES DR W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-0705
Mailing Address - Country:US
Mailing Address - Phone:904-502-3866
Mailing Address - Fax:
Practice Address - Street 1:11565 HARTS RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-3777
Practice Address - Country:US
Practice Address - Phone:904-751-1834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA8970224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant