Healthcare Provider Details

I. General information

NPI: 1588761225
Provider Name (Legal Business Name): MELINDA L LAZARUS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 09/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 CEDAR LAKE RD
NORTH BRANFORD CT
06471
US

IV. Provider business mailing address

105 MIXVILLE RD
CHESHIRE CT
06410-1967
US

V. Phone/Fax

Practice location:
  • Phone: 203-651-9203
  • Fax:
Mailing address:
  • Phone: 203-651-9203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number003086
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: