Provider Demographics
NPI:1467122069
Name:LAZAR, COLENA MABLE
Entity Type:Individual
Prefix:
First Name:COLENA
Middle Name:MABLE
Last Name:LAZAR
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 1:1204 CRYSTAL SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33540-2363
Mailing Address - Country:US
Mailing Address - Phone:813-997-5910
Mailing Address - Fax:
Practice Address - Street 1:38130 PRETTY POND RD
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33540-1419
Practice Address - Country:US
Practice Address - Phone:813-400-2291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA15829224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant