Provider Demographics
NPI:1588535363
Name:LARSON, D MYCHELE (PTA)
Entity type:Individual
Prefix:
First Name:D MYCHELE
Middle Name:
Last Name:LARSON
Suffix:
Gender:X
Credentials:PTA
Other - Prefix:
Other - First Name:D MYCHELE
Other - Middle Name:
Other - Last Name:GEORGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:2233 ACADEMY PL STE 200
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1666
Mailing Address - Country:US
Mailing Address - Phone:719-597-0822
Mailing Address - Fax:
Practice Address - Street 1:2761 JANITELL RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4102
Practice Address - Country:US
Practice Address - Phone:719-597-0822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-15
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2050290225200000X
CO0015689225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant