Healthcare Provider Details

I. General information

NPI: 1740557370
Provider Name (Legal Business Name): GEORGIANNA BLAKE LAZARUS MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5511 BANNOCK GLEN DR
CHARLOTTE NC
28212-2268
US

IV. Provider business mailing address

5511 BANNOCK GLEN DR
CHARLOTTE NC
28212-2268
US

V. Phone/Fax

Practice location:
  • Phone: 617-910-8245
  • Fax:
Mailing address:
  • Phone: 617-910-8245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC008483
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: