Basic Information
| Provider Information | |||||||||
| NPI: | 1003008806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VALENZANO | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.T | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9040 FITZSIMMONS DR | ||||||||
| Address2: | |||||||||
| City: | JOINT BASE LEWIS MCCHORD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984311000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539680780 | ||||||||
| FaxNumber: | 2539680780 | ||||||||
| Practice Location | |||||||||
| Address1: | 9040 FITZSIMMONS DR | ||||||||
| Address2: | |||||||||
| City: | JOINT BASE LEWIS MCCHORD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984311000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539680780 | ||||||||
| FaxNumber: | 2539680780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2007 | ||||||||
| LastUpdateDate: | 02/26/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 11160 | NC | N | Other Service Providers | Specialist | 225100000X | PT009916 | GA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 40QA01383400 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 116819 | 01 | GA | REHABILITATION AGENCY CERTIFICATION | OTHER | 426619 | 01 | SC | REHABILITATION AGENCY CERTIFICATION | OTHER |