Provider Demographics
NPI:1730497884
Name:LANZA, KIMBERKY (COTA/L)
Entity Type:Individual
Prefix:
First Name:KIMBERKY
Middle Name:
Last Name:LANZA
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 BURNEY BLVD
Mailing Address - Street 2:
Mailing Address - City:MASTIC
Mailing Address - State:NY
Mailing Address - Zip Code:11950-1304
Mailing Address - Country:US
Mailing Address - Phone:631-281-1517
Mailing Address - Fax:
Practice Address - Street 1:1 BRANDYWINE DR
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-5721
Practice Address - Country:US
Practice Address - Phone:631-362-0081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007357-1171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor