Healthcare Provider Details

I. General information

NPI: 1669189601
Provider Name (Legal Business Name): LACIE LAZAROE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2022
Last Update Date: 11/10/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 E FORT KING STREET
OCALA FL
34471
US

IV. Provider business mailing address

1936 BRUCE B DOWNS BLVD UNIT 486
WESLEY CHAPEL FL
33544-9262
US

V. Phone/Fax

Practice location:
  • Phone: 352-325-1882
  • Fax:
Mailing address:
  • Phone: 352-325-1884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY11690
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: