Provider Demographics
NPI:1477868388
Name:LAZENBY, TEVERLY LYNN (CMT, LMT)
Entity type:Individual
Prefix:
First Name:TEVERLY
Middle Name:LYNN
Last Name:LAZENBY
Suffix:
Gender:F
Credentials:CMT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 W COLLEGE ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-1911
Mailing Address - Country:US
Mailing Address - Phone:626-827-8836
Mailing Address - Fax:
Practice Address - Street 1:230 W COLLEGE ST
Practice Address - Street 2:SUITE E
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1911
Practice Address - Country:US
Practice Address - Phone:626-827-8836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11554225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist