Provider Demographics
NPI:1215263272
Name:LAVASSEUR, MYRNA (PT)
Entity type:Individual
Prefix:
First Name:MYRNA
Middle Name:
Last Name:LAVASSEUR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MYRNA
Other - Middle Name:TIU
Other - Last Name:MAGBOO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:136 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:HARBOR BEACH
Mailing Address - State:MI
Mailing Address - Zip Code:48441-1101
Mailing Address - Country:US
Mailing Address - Phone:989-479-3101
Mailing Address - Fax:
Practice Address - Street 1:136 N 1ST ST
Practice Address - Street 2:
Practice Address - City:HARBOR BEACH
Practice Address - State:MI
Practice Address - Zip Code:48441-1101
Practice Address - Country:US
Practice Address - Phone:989-479-3101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013184225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist