Healthcare Provider Details

I. General information

NPI: 1164931507
Provider Name (Legal Business Name): KIRSTEN ETTA LARSON LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2017
Last Update Date: 09/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3209 E 57TH AVE
SPOKANE WA
99223
US

IV. Provider business mailing address

3226 E 16TH AVE
SPOKANE WA
99223
US

V. Phone/Fax

Practice location:
  • Phone: 509-448-9398
  • Fax:
Mailing address:
  • Phone: 707-690-8936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number60763632
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: