MEDICARE: CHRISTINA MARIE LARSEN RBT

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	106S00000X	Behavior Technician	RBT-18-61946	FL

General Provider Information

NPI Number	:	1366095713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINA MARIE LARSEN RBT

Provider Business Mailing Address
First Line	:	3384 DEWBERRY CT
Second Line	:
City	:	DELTONA
State	:	FL
Zip	:	32738-1283
Country	:	US
Telephone Number	:	386-801-2784
Fax Number	:

Provider Business Practice Location Address
First Line	:	4647 CLYDE MORRIS BLVD
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-3000
Country	:	US
Telephone Number	:	386-767-3752
Fax Number	:

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

Provider Enumeration Date	:	07/24/2019
Last Update Date	:	07/24/2019

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