Healthcare Provider Details

I. General information

NPI: 1558952846
Provider Name (Legal Business Name): GERSHOM THEOPHILUS LAZARUS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2021
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 EAGLE ROW
ATLANTA GA
30322-0001
US

IV. Provider business mailing address

1215 LAVISTA RD NE
ATLANTA GA
30324-3739
US

V. Phone/Fax

Practice location:
  • Phone: 910-616-9657
  • Fax:
Mailing address:
  • Phone: 910-616-9657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY004440
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY004440
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: