Provider Demographics
NPI:1740792613
Name:LAVENDER, MICHAEL (DPT, PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:LAVENDER
Suffix:
Gender:M
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 N UNION ST
Mailing Address - Street 2:
Mailing Address - City:SPENCERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14559-1244
Mailing Address - Country:US
Mailing Address - Phone:585-349-2860
Mailing Address - Fax:585-349-2995
Practice Address - Street 1:4204 CORAL PARK DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-3016
Practice Address - Country:US
Practice Address - Phone:912-280-9205
Practice Address - Fax:912-280-0022
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041965225100000X
GAPT013932225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist