Provider Demographics
NPI:1649861337
Name:KLOTZBACH, LAUREN (PT)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:KLOTZBACH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1377 MOTOR PKWY STE 307
Mailing Address - Street 2:
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5258
Mailing Address - Country:US
Mailing Address - Phone:914-294-4050
Mailing Address - Fax:631-760-8306
Practice Address - Street 1:1714 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-2812
Practice Address - Country:US
Practice Address - Phone:267-606-6923
Practice Address - Fax:267-639-3690
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2021-04-30
Deactivation Date:2021-02-10
Deactivation Code:
Reactivation Date:2021-04-28
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01927200225100000X
PAPT029351225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist