Provider Demographics
NPI:1114779329
Name:LASCANO, MICHELLE OLVIDO
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:OLVIDO
Last Name:LASCANO
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 1:3660 E BAY DR APT 1423
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33771-1943
Mailing Address - Country:US
Mailing Address - Phone:727-492-1199
Mailing Address - Fax:
Practice Address - Street 1:1206 COURT ST
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-5802
Practice Address - Country:US
Practice Address - Phone:727-286-8408
Practice Address - Fax:727-286-6048
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT41120225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist