Provider Demographics
NPI:1023362423
Name:LAVO, JUSTIN CARL (PT, DPT)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:CARL
Last Name:LAVO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 LEVERINGTON AVE
Mailing Address - Street 2:APT 202
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19127
Mailing Address - Country:US
Mailing Address - Phone:607-221-5841
Mailing Address - Fax:610-668-0668
Practice Address - Street 1:100 PRESIDENTAL BOULEVARD
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004
Practice Address - Country:US
Practice Address - Phone:610-668-0904
Practice Address - Fax:610-668-0668
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT022464225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist