Basic Information
| Provider Information | |||||||||
| NPI: | 1780954552 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | COTA/L, RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4205 VICTORIA LAKES DR W | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322260705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9045023866 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11565 HARTS RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322183777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047511834 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2012 | ||||||||
| LastUpdateDate: | 01/10/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | OTA8970 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.