Healthcare Provider Details

I. General information

NPI: 1912565540
Provider Name (Legal Business Name): PHILLIP R LAZENBY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 N BINKLEY ST
SOLDOTNA AK
99669-7500
US

IV. Provider business mailing address

PO BOX 2127
SOLDOTNA AK
99669-2127
US

V. Phone/Fax

Practice location:
  • Phone: 907-714-4521
  • Fax: 907-260-4063
Mailing address:
  • Phone: 907-398-1161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number132467
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number132467
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: