Healthcare Provider Details

I. General information

NPI: 1609881010
Provider Name (Legal Business Name): AGNIESZKA LAZARSKA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2922 E MAPLE RD
TROY MI
48083-4495
US

IV. Provider business mailing address

4616 TIPTON DR
TROY MI
48098-4469
US

V. Phone/Fax

Practice location:
  • Phone: 248-524-4104
  • Fax:
Mailing address:
  • Phone: 248-267-0367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501004964
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: