Provider Demographics
NPI:1972991958
Name:LAZO, AMANDA GRACE (MFT-INTERN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:GRACE
Last Name:LAZO
Suffix:
Gender:F
Credentials:MFT-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 MYERS ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-5527
Mailing Address - Country:US
Mailing Address - Phone:626-827-2218
Mailing Address - Fax:
Practice Address - Street 1:3125 MYERS ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-5527
Practice Address - Country:US
Practice Address - Phone:626-827-2218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-29
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist