Basic Information
Provider Information
NPI: 1003144767
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LARSON
FirstName: MELISSA
MiddleName: S
NamePrefix:  
NameSuffix:  
Credential: DPT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 5067 55TH ST NW
Address2:  
City: ROCHESTER
State: MN
PostalCode: 559013809
CountryCode: US
TelephoneNumber: 5072927070
FaxNumber:  
Practice Location
Address1: 5067 55TH ST NW
Address2:  
City: ROCHESTER
State: MN
PostalCode: 559013809
CountryCode: US
TelephoneNumber: 5072927070
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/18/2009
LastUpdateDate: 08/12/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 08/12/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X11094MNY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 
225100000X070012902ILN Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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