Provider Demographics
NPI:1578049268
Name:LAZARO, ELLIETTA MADRIGAL (LCSW)
Entity Type:Individual
Prefix:
First Name:ELLIETTA
Middle Name:MADRIGAL
Last Name:LAZARO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 LEIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-4846
Mailing Address - Country:US
Mailing Address - Phone:301-787-9105
Mailing Address - Fax:
Practice Address - Street 1:2001 MILL RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-5355
Practice Address - Country:US
Practice Address - Phone:703-746-3599
Practice Address - Fax:703-684-2072
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904010569104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1447279658Medicaid