Provider Demographics
NPI:1043251267
Name:LARSON, JUDITH A (PT)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:LARSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:
Other - Last Name:STEVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:24014 W RENWICK RD UNIT 206
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-8711
Mailing Address - Country:US
Mailing Address - Phone:800-974-4378
Mailing Address - Fax:630-515-1536
Practice Address - Street 1:205 E HILL ST
Practice Address - Street 2:
Practice Address - City:THORP
Practice Address - State:WI
Practice Address - Zip Code:54771-7630
Practice Address - Country:US
Practice Address - Phone:800-974-4378
Practice Address - Fax:630-515-1536
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1711225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100012286Medicaid
WI40005600Medicaid
WI525589Medicare Oscar/Certification