Provider Demographics
NPI:1730257700
Name:LARSON, MICHELLE ANN (RPT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:LARSON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ANN
Other - Last Name:FOLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5778 PORCH SWING PL
Mailing Address - Street 2:
Mailing Address - City:HOSCHTON
Mailing Address - State:GA
Mailing Address - Zip Code:30548-4052
Mailing Address - Country:US
Mailing Address - Phone:770-967-3118
Mailing Address - Fax:678-573-2192
Practice Address - Street 1:1565 MOUNTCLAIRE DR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-9525
Practice Address - Country:US
Practice Address - Phone:678-362-7617
Practice Address - Fax:678-513-2192
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT004292174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist