Provider Demographics
NPI:1316112477
Name:LARSON, MICHAEL JOHN (BCHIS)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOHN
Last Name:LARSON
Suffix:
Gender:M
Credentials:BCHIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15612 WINDROSE LANE
Mailing Address - Street 2:SUITE #200
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843
Mailing Address - Country:US
Mailing Address - Phone:715-634-8736
Mailing Address - Fax:
Practice Address - Street 1:15612 WINDROSE LANE
Practice Address - Street 2:#200
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843
Practice Address - Country:US
Practice Address - Phone:715-634-8736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42839200Medicaid