Healthcare Provider Details

I. General information

NPI: 1033368279
Provider Name (Legal Business Name): MARICEL LAZO-GONZALES PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARICEL LAZO PT

II. Dates (important events)

Enumeration Date: 09/11/2008
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

459 WATCHUNG AVE
WATCHUNG NJ
07069
US

IV. Provider business mailing address

10 JOHNSTON DR
WATCHUNG NJ
07069-4905
US

V. Phone/Fax

Practice location:
  • Phone: 908-756-2424
  • Fax: 908-546-7978
Mailing address:
  • Phone: 908-756-2424
  • Fax: 908-546-7978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01012000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: