Provider Demographics
NPI:1225134026
Name:LAZORWITZ, NICOLE (PSYD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LAZORWITZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 45396
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85064-5396
Mailing Address - Country:US
Mailing Address - Phone:520-428-4528
Mailing Address - Fax:
Practice Address - Street 1:300 W CLARENDON AVE
Practice Address - Street 2:SUITE 470
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3420
Practice Address - Country:US
Practice Address - Phone:520-428-4528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4011103T00000X, 103TC0700X, 103TC1900X, 103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE96097OtherBCBS AUXILARY