Provider Demographics
NPI:1699560557
Name:LAZENBY, MADISON SHAY
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:SHAY
Last Name:LAZENBY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 PINE CIR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013-1572
Mailing Address - Country:US
Mailing Address - Phone:708-571-5404
Mailing Address - Fax:
Practice Address - Street 1:820 E TERRA COTTA AVE STE 244
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-3655
Practice Address - Country:US
Practice Address - Phone:815-354-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-11
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.006216224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant