Provider Demographics
NPI:1386947000
Name:WHITE, LARRY L (PT)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:L
Last Name:WHITE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 WHITTON STREET
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-6003
Mailing Address - Country:US
Mailing Address - Phone:520-805-5915
Mailing Address - Fax:520-364-8913
Practice Address - Street 1:365 WHITTON ST
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-1450
Practice Address - Country:US
Practice Address - Phone:520-805-5915
Practice Address - Fax:520-364-8913
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-20
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3578225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist