Provider Demographics
NPI:1043346687
Name:LARSON, MARY ST JOHN (LMT,CMTPT)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ST JOHN
Last Name:LARSON
Suffix:
Gender:F
Credentials:LMT,CMTPT
Other - Prefix:
Other - First Name:MUSCLE
Other - Middle Name:
Other - Last Name:MATTERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CMTPT
Mailing Address - Street 1:2301 PARK AVE
Mailing Address - Street 2:#209
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5565
Mailing Address - Country:US
Mailing Address - Phone:904-215-9923
Mailing Address - Fax:
Practice Address - Street 1:2301 PARK AVE
Practice Address - Street 2:#209
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5565
Practice Address - Country:US
Practice Address - Phone:904-215-9923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 39861174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC4073OtherBCBSF