Provider Demographics
NPI:1346911351
Name:LARSON, LATASHA (OT)
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19120 MYSTIQUE DR
Mailing Address - Street 2:
Mailing Address - City:CORCORAN
Mailing Address - State:MN
Mailing Address - Zip Code:55340-9586
Mailing Address - Country:US
Mailing Address - Phone:320-293-3205
Mailing Address - Fax:
Practice Address - Street 1:19120 MYSTIQUE DR
Practice Address - Street 2:
Practice Address - City:CORCORAN
Practice Address - State:MN
Practice Address - Zip Code:55340-9586
Practice Address - Country:US
Practice Address - Phone:320-293-3205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103693225X00000X, 225XG0600X, 225XE0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental Modification
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology