Provider Demographics
NPI:1124442595
Name:LARSON, KELLY (MASSAGE THERAPIST)
Entity type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 E NIXON AVE
Mailing Address - Street 2:
Mailing Address - City:CHELAN
Mailing Address - State:WA
Mailing Address - Zip Code:98816-8649
Mailing Address - Country:US
Mailing Address - Phone:509-679-7067
Mailing Address - Fax:509-888-8001
Practice Address - Street 1:11 SPOKANE ST STE 202
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-6132
Practice Address - Country:US
Practice Address - Phone:509-679-7067
Practice Address - Fax:509-888-8001
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60022016225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist