Provider Demographics
NPI:1386420289
Name:LARSON, SAMANTHA JO (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:LARSON
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 PLYMOUTH RD APT 101
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-2348
Mailing Address - Country:US
Mailing Address - Phone:952-270-8166
Mailing Address - Fax:
Practice Address - Street 1:2240 PLYMOUTH RD APT 101
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-2348
Practice Address - Country:US
Practice Address - Phone:952-270-8166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN107278225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics