Provider Demographics
NPI:1982907036
Name:LARSON, ROBERTA S (LMT)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:S
Last Name:LARSON
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 1:817 S ELM PL STE 100
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-5369
Mailing Address - Country:US
Mailing Address - Phone:918-557-6534
Mailing Address - Fax:
Practice Address - Street 1:7848 S ELM PL
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011-4353
Practice Address - Country:US
Practice Address - Phone:918-994-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-13
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101774225700000X
TXMT040151225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK101774OtherMASSAGE THERAPY BOARD/LICENSE