Provider Demographics
NPI:1437807781
Name:LARY, JAY LANCE (MA LAC NCC)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:LANCE
Last Name:LARY
Suffix:
Gender:M
Credentials:MA LAC NCC
Other - Prefix:MR
Other - First Name:J
Other - Middle Name:LANCE
Other - Last Name:LARY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA LAC NCC
Mailing Address - Street 1:6811 E MAIN ST APT 3021
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-4379
Mailing Address - Country:US
Mailing Address - Phone:480-500-7306
Mailing Address - Fax:
Practice Address - Street 1:6811 E MAIN ST APT 3021
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-4379
Practice Address - Country:US
Practice Address - Phone:480-500-7306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-16394101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health