Provider Demographics
NPI:1467725028
Name:WISDOM-LAZAR, SHELLEY (LCSW)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:WISDOM-LAZAR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:RACHELLE
Other - Middle Name:
Other - Last Name:WISDOM-LAZAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 3695
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA FE
Mailing Address - State:CA
Mailing Address - Zip Code:92067-3695
Mailing Address - Country:US
Mailing Address - Phone:619-540-7811
Mailing Address - Fax:
Practice Address - Street 1:1267 ROSECRANS ST STE E
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-2692
Practice Address - Country:US
Practice Address - Phone:619-540-7811
Practice Address - Fax:858-755-2416
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-13
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASW610461041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical