Provider Demographics
NPI:1598427833
Name:LARSEN, LORI AUGUSTA (MESSAGE THERAPIST)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:AUGUSTA
Last Name:LARSEN
Suffix:
Gender:F
Credentials:MESSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 447
Mailing Address - Street 2:
Mailing Address - City:REDGRANITE
Mailing Address - State:WI
Mailing Address - Zip Code:54970-0447
Mailing Address - Country:US
Mailing Address - Phone:920-566-0767
Mailing Address - Fax:920-566-0768
Practice Address - Street 1:1100 E BANNERMAN AVE # 2
Practice Address - Street 2:
Practice Address - City:REDGRANITE
Practice Address - State:WI
Practice Address - Zip Code:54970-9320
Practice Address - Country:US
Practice Address - Phone:920-566-0767
Practice Address - Fax:920-566-0768
Is Sole Proprietor?:No
Enumeration Date:2021-10-13
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2116-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist