Healthcare Provider Details

I. General information

NPI: 1902653553
Provider Name (Legal Business Name): TIFFANY KINUGAWA-LARSEN OTD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2024
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8675 W ROME BLVD STE 140
LAS VEGAS NV
89149-1291
US

IV. Provider business mailing address

8675 W ROME BLVD STE 140
LAS VEGAS NV
89149-1291
US

V. Phone/Fax

Practice location:
  • Phone: 772-520-6792
  • Fax: 725-206-7930
Mailing address:
  • Phone: 725-206-7929
  • Fax: 725-206-7930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN524000
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number827523
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberOT-3944
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: