Provider Demographics
NPI:1780947440
Name:KYZAR, LODIE NYCOL (PT)
Entity type:Individual
Prefix:
First Name:LODIE
Middle Name:NYCOL
Last Name:KYZAR
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 1:536 HALF MOON LN
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-5576
Mailing Address - Country:US
Mailing Address - Phone:318-623-2014
Mailing Address - Fax:
Practice Address - Street 1:536 HALF MOON LN
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-5576
Practice Address - Country:US
Practice Address - Phone:318-623-2014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA078032251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics