Provider Demographics
NPI:1124063615
Name:LEZOTTE, GINETTE ALICIA (AUD)
Entity type:Individual
Prefix:DR
First Name:GINETTE
Middle Name:ALICIA
Last Name:LEZOTTE
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:DR
Other - First Name:GINETTE
Other - Middle Name:ALICIA
Other - Last Name:RUCKEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:20239 MACK AVENUE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1769
Mailing Address - Country:US
Mailing Address - Phone:313-343-5555
Mailing Address - Fax:313-343-5304
Practice Address - Street 1:20239 MACK AVENUE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-1769
Practice Address - Country:US
Practice Address - Phone:313-343-5555
Practice Address - Fax:313-343-5304
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000010237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540H214720OtherBCBSM
MI126065OtherGREAT LAKES HEALTH
MI202114OtherTOTAL HEALTH CARE
MI804683505Medicaid
MI904396202Medicaid
MI0N49120OtherHEALTH ALLIANCE PLAN
MI640H227080OtherBCBSM
MI904396202Medicaid