Healthcare Provider Details

I. General information

NPI: 1811816275
Provider Name (Legal Business Name): AUDRA LARSON OTD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85C VINCENT DR
MT PLEASANT SC
29464-4030
US

IV. Provider business mailing address

152 W WILKSHIRE PL
BRISTOL TN
37620-7786
US

V. Phone/Fax

Practice location:
  • Phone: 843-822-2292
  • Fax: 888-588-3421
Mailing address:
  • Phone: 276-696-1684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number8032
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: