Provider Demographics
NPI:1154305886
Name:BAZLEY, LISA CONNELLY (PT)
Entity Type:Individual
Prefix:MR
First Name:LISA
Middle Name:CONNELLY
Last Name:BAZLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 COOPER AVE
Mailing Address - Street 2:
Mailing Address - City:WEST LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07764-1214
Mailing Address - Country:US
Mailing Address - Phone:732-263-9474
Mailing Address - Fax:732-263-9475
Practice Address - Street 1:16 COOPER AVE
Practice Address - Street 2:
Practice Address - City:WEST LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07764-1214
Practice Address - Country:US
Practice Address - Phone:732-263-9474
Practice Address - Fax:732-263-9475
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA03737225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ038494Medicare ID - Type UnspecifiedMEDICARE NUMBER