Provider Demographics
NPI:1306195151
Name:LAZARUS PROJECT GROUP PLLC
Entity Type:Organization
Organization Name:LAZARUS PROJECT GROUP PLLC
Other - Org Name:LAZARUS PROJECT GROUP PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:COUNSELOR - OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROLLA
Authorized Official - Middle Name:MERLE
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:LPC-S
Authorized Official - Phone:210-859-5446
Mailing Address - Street 1:9352 OSAGE CIR
Mailing Address - Street 2:
Mailing Address - City:GARDEN RIDGE
Mailing Address - State:TX
Mailing Address - Zip Code:78266-2060
Mailing Address - Country:US
Mailing Address - Phone:210-859-5446
Mailing Address - Fax:
Practice Address - Street 1:19185 FM 2252
Practice Address - Street 2:
Practice Address - City:GARDEN RIDGE
Practice Address - State:TX
Practice Address - Zip Code:78266-2574
Practice Address - Country:US
Practice Address - Phone:210-859-5446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14527101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty