Provider Demographics
NPI:1912565540
Name:LAZENBY, PHILLIP R
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:R
Last Name:LAZENBY
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:PO BOX 2127
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-2127
Mailing Address - Country:US
Mailing Address - Phone:907-398-1161
Mailing Address - Fax:
Practice Address - Street 1:245 N BINKLEY ST
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7500
Practice Address - Country:US
Practice Address - Phone:907-714-4521
Practice Address - Fax:907-260-4063
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK132467101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor