Healthcare Provider Details

I. General information

NPI: 1083503825
Provider Name (Legal Business Name): CAROL M LAZO, LICENSED PROFESSIONAL CLINICAL COUNSELOR P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2025
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 WILSHIRE BLVD STE 204
SANTA MONICA CA
90401-1737
US

IV. Provider business mailing address

13389 FOLSOM BLVD #200
FOLSOM CA
95630
US

V. Phone/Fax

Practice location:
  • Phone: 424-488-6422
  • Fax: 213-652-6332
Mailing address:
  • Phone: 424-488-6422
  • Fax: 213-652-6332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License Number
License Number State

VIII. Authorized Official

Name: CAROL M LAZO
Title or Position: PRESIDENT
Credential: LPCC
Phone: 424-488-6422