Healthcare Provider Details

I. General information

NPI: 1740437987
Provider Name (Legal Business Name): RICHARD LARSON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 08/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 FRANKLIN ST
NORTH ADAMS MA
01247-2712
US

IV. Provider business mailing address

33 MAIN ST P.O. BOX715
GOSHEN MA
01032-9608
US

V. Phone/Fax

Practice location:
  • Phone: 413-664-4041
  • Fax:
Mailing address:
  • Phone: 413-268-3562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number8220
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: