Healthcare Provider Details

I. General information

NPI: 1558707869
Provider Name (Legal Business Name): ELANNA LAZARUK PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2013
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 REGENT PARK DR
LA CANADA FLINTRIDGE CA
91011-4158
US

IV. Provider business mailing address

975 REGENT PARK DR
LA CANADA FLINTRIDGE CA
91011-4158
US

V. Phone/Fax

Practice location:
  • Phone: 914-500-8448
  • Fax: 818-495-5387
Mailing address:
  • Phone: 914-500-8448
  • Fax: 818-495-5387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY32693
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number020118
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: