Healthcare Provider Details

I. General information

NPI: 1780820886
Provider Name (Legal Business Name): KENNETH CHRISTOPHER LAZZARA PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2008
Last Update Date: 03/07/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9160 FORUM CORPORATE PKWY STE 350
FORT MYERS FL
33905-7808
US

IV. Provider business mailing address

9160 FORUM CORPORATE PKWY STE 350
FORT MYERS FL
33905-7808
US

V. Phone/Fax

Practice location:
  • Phone: 239-391-7313
  • Fax:
Mailing address:
  • Phone: 239-391-7313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301010699
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY11760
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: