Provider Demographics
NPI:1477881365
Name:LACSON, WILMER AVANCY
Entity Type:Individual
Prefix:
First Name:WILMER
Middle Name:AVANCY
Last Name:LACSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 E 108TH ST
Mailing Address - Street 2:2C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-4245
Mailing Address - Country:US
Mailing Address - Phone:917-484-1465
Mailing Address - Fax:
Practice Address - Street 1:66 CRISFIELD ST
Practice Address - Street 2:UNIT 1-Q
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10710-1243
Practice Address - Country:US
Practice Address - Phone:917-484-1465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-03
Last Update Date:2016-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0157731225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist