Provider Demographics
NPI:1780619429
Name:CLOUD MALENCZAK, LOIS (PT)
Entity type:Individual
Prefix:
First Name:LOIS
Middle Name:
Last Name:CLOUD MALENCZAK
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 1:1 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-2663
Mailing Address - Country:US
Mailing Address - Phone:631-563-8400
Mailing Address - Fax:631-589-5582
Practice Address - Street 1:1 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-2663
Practice Address - Country:US
Practice Address - Phone:631-563-8400
Practice Address - Fax:631-589-5582
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005871-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist