Healthcare Provider Details

I. General information

NPI: 1538482443
Provider Name (Legal Business Name): GRAIG LARSEN PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2010
Last Update Date: 03/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL RD SUITE 112
EAST PATCHOGUE NY
11772-8809
US

IV. Provider business mailing address

100 HOSPITAL RD SUITE 112
EAST PATCHOGUE NY
11772-8809
US

V. Phone/Fax

Practice location:
  • Phone: 631-456-5512
  • Fax: 631-456-5514
Mailing address:
  • Phone: 631-456-5512
  • Fax: 631-456-5514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number032030
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: