Provider Demographics
NPI:1891332813
Name:LIZEN, REY MARK
Entity Type:Individual
Prefix:
First Name:REY MARK
Middle Name:
Last Name:LIZEN
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 1:8722 51ST AVE APT 2E
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4183
Mailing Address - Country:US
Mailing Address - Phone:646-479-8555
Mailing Address - Fax:
Practice Address - Street 1:6970 GRAND CENTRAL PKWY
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-3949
Practice Address - Country:US
Practice Address - Phone:718-263-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042155225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist