Provider Demographics
NPI:1417505702
Name:GARZA, LAURIE LYNNE (LPT)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:LYNNE
Last Name:GARZA
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2877 LANCER AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-2513
Mailing Address - Country:US
Mailing Address - Phone:909-938-7306
Mailing Address - Fax:
Practice Address - Street 1:5335 CRANER AVE
Practice Address - Street 2:
Practice Address - City:N HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91601-3313
Practice Address - Country:US
Practice Address - Phone:818-927-4045
Practice Address - Fax:818-927-4016
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CA25538167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1417505702Medicaid