Provider Demographics
NPI:1164166351
Name:LAZO, ROSELYN MARIE
Entity Type:Individual
Prefix:
First Name:ROSELYN
Middle Name:MARIE
Last Name:LAZO
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 1:400 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALICE
Mailing Address - State:TX
Mailing Address - Zip Code:78332-4969
Mailing Address - Country:US
Mailing Address - Phone:361-396-4029
Mailing Address - Fax:
Practice Address - Street 1:400 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ALICE
Practice Address - State:TX
Practice Address - Zip Code:78332-4969
Practice Address - Country:US
Practice Address - Phone:956-233-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-24
Last Update Date:2022-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216377224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant