Provider Demographics
NPI:1609024520
Name:LARSON, DUSTIN ADAM (MA, CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:ADAM
Last Name:LARSON
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 JAMES ST.
Mailing Address - Street 2:
Mailing Address - City:VERMILLION
Mailing Address - State:SD
Mailing Address - Zip Code:57069
Mailing Address - Country:US
Mailing Address - Phone:605-670-0696
Mailing Address - Fax:
Practice Address - Street 1:900 JAMES ST
Practice Address - Street 2:
Practice Address - City:VERMILLION
Practice Address - State:SD
Practice Address - Zip Code:57069-1012
Practice Address - Country:US
Practice Address - Phone:605-670-0696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD235Z00000X
IA001898235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist