MEDICARE: SHELLEY WISDOM-LAZAR LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW61046	CA

General Provider Information

NPI Number	:	1467725028
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELLEY WISDOM-LAZAR LCSW

Provider Business Mailing Address
First Line	:	PO BOX 3695
Second Line	:
City	:	RANCHO SANTA FE
State	:	CA
Zip	:	92067-3695
Country	:	US
Telephone Number	:	619-540-7811
Fax Number	:

Provider Business Practice Location Address
First Line	:	1267 ROSECRANS ST STE E
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92106-2692
Country	:	US
Telephone Number	:	619-540-7811
Fax Number	:	858-755-2416

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2012
Last Update Date	:	06/09/2021

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