Healthcare Provider Details

I. General information

NPI: 1013841816
Provider Name (Legal Business Name): BROOKE LARSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16650 SHERMAN WAY
VAN NUYS CA
91406-3782
US

IV. Provider business mailing address

5548 DE VORE CT
AGOURA HILLS CA
91301-2247
US

V. Phone/Fax

Practice location:
  • Phone: 818-425-6551
  • Fax:
Mailing address:
  • Phone: 818-689-2029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: