Provider Demographics
NPI:1093259202
Name:LAZZARO, MARIA GRACE (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:GRACE
Last Name:LAZZARO
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2417 AIRPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-4315
Mailing Address - Country:US
Mailing Address - Phone:540-772-7267
Mailing Address - Fax:
Practice Address - Street 1:10255 BEACH DR SW
Practice Address - Street 2:
Practice Address - City:CALABASH
Practice Address - State:NC
Practice Address - Zip Code:28467-2703
Practice Address - Country:US
Practice Address - Phone:540-772-7267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-06
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0021941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical