Healthcare Provider Details

I. General information

NPI: 1346756954
Provider Name (Legal Business Name): REBECCA LARSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2017
Last Update Date: 12/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12350 ESSINGTON RD
PLAINFIELD IL
60585-9528
US

IV. Provider business mailing address

25029 ARMSTRONG LN
PLAINFIELD IL
60585-5798
US

V. Phone/Fax

Practice location:
  • Phone: 815-439-8024
  • Fax:
Mailing address:
  • Phone: 815-325-0281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number242004696
License Number StateIL

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: