Provider Demographics
NPI:1356638753
Name:LAZELL, MALLORY (DPT)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:LAZELL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLE GLADE
Mailing Address - State:FL
Mailing Address - Zip Code:33430-4910
Mailing Address - Country:US
Mailing Address - Phone:561-996-7032
Mailing Address - Fax:
Practice Address - Street 1:1100 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLE GLADE
Practice Address - State:FL
Practice Address - Zip Code:33430-4910
Practice Address - Country:US
Practice Address - Phone:561-996-7032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2012-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT26554225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL887989300Medicaid
FL887989300Medicaid