Healthcare Provider Details

I. General information

NPI: 1679074280
Provider Name (Legal Business Name): GEORGE ALEXANDER FUTCH LAZO JR. PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 01/09/2021
Certification Date: 01/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 CLARK WAY
PALO ALTO CA
94304-2300
US

IV. Provider business mailing address

650 CLARK WAY
PALO ALTO CA
94304-2300
US

V. Phone/Fax

Practice location:
  • Phone: 650-617-3823
  • Fax: 650-688-3669
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number29901
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: