Provider Demographics
NPI:1679074462
Name:LAZENBY, SUSAN CAROL
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:CAROL
Last Name:LAZENBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7445 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1963
Mailing Address - Country:US
Mailing Address - Phone:313-389-5600
Mailing Address - Fax:
Practice Address - Street 1:7445 ALLEN RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-1963
Practice Address - Country:US
Practice Address - Phone:313-389-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501002541225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI38-1357020Medicaid