Provider Demographics
NPI:1225781677
Name:BERNAL, LORENZO RAPHAEL PALACIOS (PTA)
Entity type:Individual
Prefix:
First Name:LORENZO RAPHAEL
Middle Name:PALACIOS
Last Name:BERNAL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8808 JUSTICE AVE APT 5K
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-5333
Mailing Address - Country:US
Mailing Address - Phone:929-346-8212
Mailing Address - Fax:
Practice Address - Street 1:8808 JUSTICE AVE APT 5K
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5333
Practice Address - Country:US
Practice Address - Phone:929-346-8212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-26
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04036901225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist