Provider Demographics
NPI:1700177896
Name:LARSEN, STEFANIE
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 STANDISH RD
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-2346
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 MAGUIRE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421
Practice Address - Country:US
Practice Address - Phone:781-860-1769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-25
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10316225X00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty