Provider Demographics
NPI:1891332300
Name:LAZNOVSKY, JOHNATHAN JAMES (LMT)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:JAMES
Last Name:LAZNOVSKY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 LINCOLN AVE UNIT 11
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-2257
Mailing Address - Country:US
Mailing Address - Phone:631-256-5184
Mailing Address - Fax:
Practice Address - Street 1:920 LINCOLN AVE UNIT 11
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-2257
Practice Address - Country:US
Practice Address - Phone:631-256-5184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032030225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist