Provider Demographics
NPI:1497281836
Name:CAVALLO, LACEY (DPT)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:CAVALLO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-1742
Mailing Address - Country:US
Mailing Address - Phone:516-330-9213
Mailing Address - Fax:
Practice Address - Street 1:464 GRAND BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-1742
Practice Address - Country:US
Practice Address - Phone:516-330-9213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0331971225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist