Individual
MR. BROCK RUSSELL LARSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PTA
Contact information
Practice address
9180 KATY FWY STE 200, HOUSTON, TX 77055-7443
(713) 984-1400
Mailing address
310 E HEARD ST, GANADO, TX 77962-8413
(361) 771-5956
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
2062500
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2062500
PTA LICENSCE
TX
Enumeration date
06/16/2008
Last updated
06/16/2008
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