Provider Demographics
NPI:1831302686
Name:BENNELL-LAZARUS, MOLLIE LOUISE (MOLLIE BENNELL-LAZAR)
Entity type:Individual
Prefix:MS
First Name:MOLLIE
Middle Name:LOUISE
Last Name:BENNELL-LAZARUS
Suffix:
Gender:F
Credentials:MOLLIE BENNELL-LAZAR
Other - Prefix:
Other - First Name:MOLLIE
Other - Middle Name:
Other - Last Name:BENNELL-LAZARUS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MOLLIE BENNELL-LAZAR
Mailing Address - Street 1:2135 VIA TECA
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-5649
Mailing Address - Country:US
Mailing Address - Phone:949-361-4726
Mailing Address - Fax:949-492-5608
Practice Address - Street 1:3 PURSUIT
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-4213
Practice Address - Country:US
Practice Address - Phone:949-389-8549
Practice Address - Fax:949-362-9083
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT13340225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist