Provider Demographics
NPI:1801275003
Name:LARGE, KIRSTEN (LMT)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:LARGE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 PUTNAM PIKE
Mailing Address - Street 2:UNIT 3
Mailing Address - City:DAYVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06241-1608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 PUTNAM PIKE
Practice Address - Street 2:UNIT 3
Practice Address - City:DAYVILLE
Practice Address - State:CT
Practice Address - Zip Code:06241-1608
Practice Address - Country:US
Practice Address - Phone:860-412-9016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8537225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist