Provider Demographics
NPI:1386075687
Name:LAZENBY, TODD (MA, ATC)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:LAZENBY
Suffix:
Gender:M
Credentials:MA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:953 DANBY RD
Mailing Address - Street 2:G68 HILL CENTER
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-7000
Mailing Address - Country:US
Mailing Address - Phone:607-274-1717
Mailing Address - Fax:
Practice Address - Street 1:953 DANBY RD
Practice Address - Street 2:G68 HILL CENTER
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-7000
Practice Address - Country:US
Practice Address - Phone:607-274-1717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001573-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer