MEDICARE: DENA LARSEN DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	225100000X	Physical Therapist	PT60095067	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PU60095046	OTHER	WA	INTERIM PERMIT

General Provider Information

NPI Number	:	1225267206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENA LARSEN DPT

Provider Business Mailing Address
First Line	:	4851 AUTO CENTER WAY
Second Line	:
City	:	BREMERTON
State	:	WA
Zip	:	98312-4308
Country	:	US
Telephone Number	:	360-627-7768
Fax Number	:	360-627-8003

Provider Business Practice Location Address
First Line	:	451 SW SEDGWICK RD
Second Line	:	STE. 310
City	:	PORT ORCHARD
State	:	WA
Zip	:	98367-6447
Country	:	US
Telephone Number	:	360-874-8009
Fax Number	:	360-874-8010

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2009
Last Update Date	:	08/09/2023

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