Provider Demographics
NPI:1821752460
Name:LAZARUS, ADAM WYATT (CTRS)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:WYATT
Last Name:LAZARUS
Suffix:
Gender:M
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18441 NW 2ND AVE STE 505
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-4562
Mailing Address - Country:US
Mailing Address - Phone:786-657-3276
Mailing Address - Fax:
Practice Address - Street 1:18441 NW 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33169-4517
Practice Address - Country:US
Practice Address - Phone:786-657-3276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL66184225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist