Provider Demographics
NPI:1194078972
Name:FALLEN, LEZERIC ANZEL (OTA)
Entity type:Individual
Prefix:MR
First Name:LEZERIC
Middle Name:ANZEL
Last Name:FALLEN
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1157 S KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-2737
Mailing Address - Country:US
Mailing Address - Phone:812-402-0460
Mailing Address - Fax:
Practice Address - Street 1:1157 S KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-2737
Practice Address - Country:US
Practice Address - Phone:812-402-0460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32000566A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant