Provider Demographics
NPI:1033801154
Name:LAVRACK, MARK W JR (PTA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:W
Last Name:LAVRACK
Suffix:JR
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 1:111 S MICHIGAN AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-2724
Mailing Address - Country:US
Mailing Address - Phone:989-213-3932
Mailing Address - Fax:
Practice Address - Street 1:111 S MICHIGAN AVE APT 101
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-2724
Practice Address - Country:US
Practice Address - Phone:989-213-3932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502005718225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant