Provider Demographics
NPI:1265392104
Name:LARSEN, DANIEL P (PTA)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:P
Last Name:LARSEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 HARLOW CRES
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-5236
Mailing Address - Country:US
Mailing Address - Phone:201-691-5164
Mailing Address - Fax:
Practice Address - Street 1:23-00 ROUTE 208 STE 1-6
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-1558
Practice Address - Country:US
Practice Address - Phone:201-796-1138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-13
Last Update Date:2025-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00401700225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty