Healthcare Provider Details

I. General information

NPI: 1790410793
Provider Name (Legal Business Name): MRS. STEPHANIE ANN LARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2022
Last Update Date: 07/22/2022
Certification Date: 07/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4121 E VALLEY AUTO DR # 100
MESA AZ
85206-4631
US

IV. Provider business mailing address

5615 E ENROSE ST
MESA AZ
85205-5857
US

V. Phone/Fax

Practice location:
  • Phone: 480-687-4271
  • Fax: 480-422-2436
Mailing address:
  • Phone: 148-098-1792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number006336
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: