Provider Demographics
NPI:1528259082
Name:MENGELKOCH, LARRY JON (PHD, PT)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:JON
Last Name:MENGELKOCH
Suffix:
Gender:M
Credentials:PHD, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5715 NW 67TH CT
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32653-3208
Mailing Address - Country:US
Mailing Address - Phone:352-505-3509
Mailing Address - Fax:352-505-3509
Practice Address - Street 1:5715 NW 67TH CT
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32653-3208
Practice Address - Country:US
Practice Address - Phone:352-505-3509
Practice Address - Fax:352-505-3509
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 4560225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist