Provider Demographics
NPI:1518307792
Name:LAZARUS, ALEXIS FAWN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:FAWN
Last Name:LAZARUS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 CHEROKEE LN
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-4604
Mailing Address - Country:US
Mailing Address - Phone:631-241-1284
Mailing Address - Fax:
Practice Address - Street 1:4 CHEROKEE LN
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-4604
Practice Address - Country:US
Practice Address - Phone:631-241-1284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-02
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024009235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist