Healthcare Provider Details

I. General information

NPI: 1558669291
Provider Name (Legal Business Name): SANDRA LARSEN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2011
Last Update Date: 03/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 70TH ST
BROOKLYN NY
11228-1013
US

IV. Provider business mailing address

850 70TH ST
BROOKLYN NY
11228-1013
US

V. Phone/Fax

Practice location:
  • Phone: 917-971-9663
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number022541
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: