Healthcare Provider Details

I. General information

NPI: 1225134026
Provider Name (Legal Business Name): NICOLE LAZORWITZ PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W CLARENDON AVE SUITE 470
PHOENIX AZ
85013-3420
US

IV. Provider business mailing address

PO BOX 45396
PHOENIX AZ
85064-5396
US

V. Phone/Fax

Practice location:
  • Phone: 520-428-4528
  • Fax:
Mailing address:
  • Phone: 520-428-4528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4011
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4011
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number4011
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number4011
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: