Provider Demographics
NPI:1124111372
Name:LARSEN, ROBERT J (MPT ATG)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:J
Last Name:LARSEN
Suffix:
Gender:M
Credentials:MPT ATG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 S RENAISSANCE TWN DR
Mailing Address - Street 2:SUITE 420
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010
Mailing Address - Country:US
Mailing Address - Phone:801-295-8999
Mailing Address - Fax:801-292-4168
Practice Address - Street 1:1551 S RENAISSANCE TWN DR
Practice Address - Street 2:SUITE 420
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010
Practice Address - Country:US
Practice Address - Phone:801-295-8999
Practice Address - Fax:801-292-4168
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2780262401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist