Healthcare Provider Details

I. General information

NPI: 1417205337
Provider Name (Legal Business Name): GREGORY LAZZARA LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 WINN WAY
DECATUR GA
30030-1707
US

IV. Provider business mailing address

445 WINN WAY
DECATUR GA
30030-1707
US

V. Phone/Fax

Practice location:
  • Phone: 404-294-3745
  • Fax:
Mailing address:
  • Phone: 404-294-3745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178-007226
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC009197
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: