Provider Demographics
NPI:1487706875
Name:LARSON, ANN (PT)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 1ST AVE W
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:SD
Mailing Address - Zip Code:57225-1405
Mailing Address - Country:US
Mailing Address - Phone:605-532-4212
Mailing Address - Fax:
Practice Address - Street 1:312 1ST AVE W
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:SD
Practice Address - Zip Code:57225-1405
Practice Address - Country:US
Practice Address - Phone:605-532-4212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1194225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4997989OtherBCBS OF SD
SD21256OtherSVC HEALTHPLAN
SD7079OtherAVERA HEALTHPLAN
SD5833542Medicaid
SD21256OtherSVC HEALTHPLAN
SD5833542Medicaid