Provider Demographics
NPI:1508410259
Name:LAZARUS, MICHAEL ALAN SR (CATC-II, CAODC-A)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ALAN
Last Name:LAZARUS
Suffix:SR
Gender:M
Credentials:CATC-II, CAODC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-5933
Mailing Address - Country:US
Mailing Address - Phone:619-488-7612
Mailing Address - Fax:619-327-5410
Practice Address - Street 1:525 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977-5933
Practice Address - Country:US
Practice Address - Phone:619-488-7612
Practice Address - Fax:619-327-5410
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
0415192210OtherHEALTHCARE PROVIDERS SERVICE ORGANIZATION