Basic Information
| Provider Information | |||||||||
| NPI: | 1730857285 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | GRAYDON | ||||||||
| MiddleName: | DAN | ||||||||
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| Credential: | MOT, OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2646 LEGENDS CIR | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834044801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013863967 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1460 ELK CREEK DR | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834048237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085351286 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2021 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X | OT-1809 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
No ID Information.