Provider Demographics
NPI:1881460293
Name:LAZCON, DESIREE MARIE (LMT)
Entity type:Individual
Prefix:MRS
First Name:DESIREE
Middle Name:MARIE
Last Name:LAZCON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MISS
Other - First Name:DESIREE
Other - Middle Name:MARIE
Other - Last Name:NORVAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4900 SPRING ST STE 101
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-2920
Mailing Address - Country:US
Mailing Address - Phone:262-320-7323
Mailing Address - Fax:
Practice Address - Street 1:4900 SPRING ST STE 101
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-2920
Practice Address - Country:US
Practice Address - Phone:262-320-7323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14905-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist