Healthcare Provider Details

I. General information

NPI: 1891260485
Provider Name (Legal Business Name): LAZZARO PSYCHOLOGICAL SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 MAIN ST STE 105
PARK RIDGE IL
60068-4059
US

IV. Provider business mailing address

36 MAIN ST STE 105
PARK RIDGE IL
60068-4059
US

V. Phone/Fax

Practice location:
  • Phone: 847-712-1445
  • Fax:
Mailing address:
  • Phone: 847-712-1445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. BRIAN RICHARD LAZZARO
Title or Position: OWNER - CLINICAL PSYCHOLOGIST
Credential: PH.D.
Phone: 847-712-1445