MEDICARE: LIEZL GRACE A LONZAME

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251P0200X	Pediatric Physical Therapist	023863	NY

General Provider Information

NPI Number	:	1124272778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIEZL GRACE A LONZAME

Provider Business Mailing Address
First Line	:	2714 HARDING AVE
Second Line	:	2ND FLOOR
City	:	BRONX
State	:	NY
Zip	:	10465-3130
Country	:	US
Telephone Number	:	646-644-0342
Fax Number	:

Provider Business Practice Location Address
First Line	:	2714 HARDING AVE
Second Line	:	2ND FLOOR
City	:	BRONX
State	:	NY
Zip	:	10465-3130
Country	:	US
Telephone Number	:	646-644-0342
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2008
Last Update Date	:	11/10/2008

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