Provider Demographics
NPI:1699826792
Name:LAZAR, LISA MAREMS (PHD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MAREMS
Last Name:LAZAR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 B AVE
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-1511
Mailing Address - Country:US
Mailing Address - Phone:619-970-1960
Mailing Address - Fax:619-226-0402
Practice Address - Street 1:138 B AVE
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-1511
Practice Address - Country:US
Practice Address - Phone:619-970-1960
Practice Address - Fax:619-226-0402
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12354103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP12354Medicare UPIN