Provider Demographics
NPI:1760849178
Name:LAZARIS, NICHOLAS
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:LAZARIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20709 CALLE PERA
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-4638
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18210 YORBA LINDA BLVD
Practice Address - Street 2:SUITE 404
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-4059
Practice Address - Country:US
Practice Address - Phone:714-779-9964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-15
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7038103TB0200X, 103TC0700X, 103TE1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports