Provider Demographics
NPI:1326445867
Name:HERZOG, LARA KRISTINE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:KRISTINE
Last Name:HERZOG
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:KRISTINE
Other - Last Name:SPIEGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT DPT
Mailing Address - Street 1:BOX 8000
Mailing Address - Street 2:DEPT 314
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14267-0002
Mailing Address - Country:US
Mailing Address - Phone:716-213-0772
Mailing Address - Fax:716-324-5004
Practice Address - Street 1:48 DOUGLAS LN
Practice Address - Street 2:
Practice Address - City:EAST AURORA
Practice Address - State:NY
Practice Address - Zip Code:14052-2124
Practice Address - Country:US
Practice Address - Phone:716-714-9860
Practice Address - Fax:716-714-9864
Is Sole Proprietor?:No
Enumeration Date:2014-11-26
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10948225100000X
SC7537225100000X
NY038070225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05899665Medicaid