Provider Demographics
NPI:1558952846
Name:LAZARUS, GERSHOM THEOPHILUS (PHD)
Entity Type:Individual
Prefix:DR
First Name:GERSHOM
Middle Name:THEOPHILUS
Last Name:LAZARUS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 LAVISTA RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-3739
Mailing Address - Country:US
Mailing Address - Phone:910-616-9657
Mailing Address - Fax:
Practice Address - Street 1:36 EAGLE ROW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-0001
Practice Address - Country:US
Practice Address - Phone:910-616-9657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004440103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty