Healthcare Provider Details

I. General information

NPI: 1235839762
Provider Name (Legal Business Name): THOMAS LAZO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2023
Last Update Date: 03/03/2023
Certification Date: 03/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40015 SIERRA HWY STE B280
PALMDALE CA
93550-2143
US

IV. Provider business mailing address

40015 SIERRA HWY STE B280
PALMDALE CA
93550-2143
US

V. Phone/Fax

Practice location:
  • Phone: 909-843-7034
  • Fax:
Mailing address:
  • Phone: 909-843-7034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number136313
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: