MEDICARE: SUSAN LARSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist		IL

General Provider Information

NPI Number	:	1184835308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN LARSON

Provider Business Mailing Address
First Line	:	15357 W WILDWOOD CT
Second Line	:
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048-1496
Country	:	US
Telephone Number	:	847-370-8729
Fax Number	:	847-557-9811

Provider Business Practice Location Address
First Line	:	15357 W WILDWOOD CT
Second Line	:
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048-1496
Country	:	US
Telephone Number	:	847-370-8729
Fax Number	:	847-557-9811

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2007
Last Update Date	:	07/08/2007

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Directions to “ SUSAN LARSON ” Practice Location

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