Basic Information
Provider Information
NPI: 1003294133
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LARSEN
FirstName: KATHRYN
MiddleName: N
NamePrefix:  
NameSuffix:  
Credential: PT, DPT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: LARSEN
OtherFirstName: KATHY
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: PT, DPT
OtherLastNameType: 2
Mailing Information
Address1: 60 PEMBROKE ST
Address2:  
City: NEWTON
State: MA
PostalCode: 024582449
CountryCode: US
TelephoneNumber: 6179643314
FaxNumber:  
Practice Location
Address1: 60 PEMBROKE ST
Address2:  
City: NEWTON
State: MA
PostalCode: 024582449
CountryCode: US
TelephoneNumber: 6179643314
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/08/2015
LastUpdateDate: 07/21/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X9578MAY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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