Provider Demographics
NPI:1194910547
Name:LAVIOLETTE, SUSAN (PT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:LAVIOLETTE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 BEDFORD ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-4320
Mailing Address - Country:US
Mailing Address - Phone:781-861-8884
Mailing Address - Fax:
Practice Address - Street 1:35 BEDFORD ST
Practice Address - Street 2:SUITE 5
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-4320
Practice Address - Country:US
Practice Address - Phone:781-861-8884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3625225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY65113OtherBLUE CROSS
MAY68031Medicare PIN