Basic Information
| Provider Information | |||||||||
| NPI: | 1326445867 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERZOG | ||||||||
| FirstName: | LARA | ||||||||
| MiddleName: | KRISTINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SPIEGEL | ||||||||
| OtherFirstName: | LARA | ||||||||
| OtherMiddleName: | KRISTINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | BOX 8000 | ||||||||
| Address2: | DEPT 314 | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142670002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162130772 | ||||||||
| FaxNumber: | 7163245004 | ||||||||
| Practice Location | |||||||||
| Address1: | 48 DOUGLAS LN | ||||||||
| Address2: | |||||||||
| City: | EAST AURORA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140522124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167149860 | ||||||||
| FaxNumber: | 7167149864 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2014 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 10948 | TN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 7537 | SC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 038070 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 05899665 | 05 | NY | MEDICAID |