Provider Demographics
NPI:1639651516
Name:LAZENBY, ILENE F
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:F
Last Name:LAZENBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ILENE
Other - Middle Name:FRANCES
Other - Last Name:INMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1670 E 440 S
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-3765
Mailing Address - Country:US
Mailing Address - Phone:801-502-5034
Mailing Address - Fax:
Practice Address - Street 1:90 E 200 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4034
Practice Address - Country:US
Practice Address - Phone:435-752-0750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
UT11841805-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical