Provider Demographics
NPI:1366763625
Name:LARSON, THOMAS M (MPT)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:LARSON
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3470 RUSTLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-3840
Mailing Address - Country:US
Mailing Address - Phone:850-727-5406
Mailing Address - Fax:850-727-5764
Practice Address - Street 1:1989 CAPITAL CIR NE
Practice Address - Street 2:SUITE 9
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4493
Practice Address - Country:US
Practice Address - Phone:850-727-5406
Practice Address - Fax:850-727-5764
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19145225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008872100Medicaid
FLY09JUOtherBCBSFL
FLPT19145OtherFLORIDA LICENSE
FL008872100Medicaid