Provider Demographics
NPI:1942278718
Name:DALZELL, LARRY EUGENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:EUGENE
Last Name:DALZELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 GLENHILL DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-3933
Mailing Address - Country:US
Mailing Address - Phone:585-442-6392
Mailing Address - Fax:
Practice Address - Street 1:2561 LAC DE VILLE BLVD
Practice Address - Street 2:# 101
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-5645
Practice Address - Country:US
Practice Address - Phone:585-461-9192
Practice Address - Fax:585-461-9196
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000386-1231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA5381Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBE
NY17571AMedicare ID - Type UnspecifiedGROUP PRACTICE MC #