Healthcare Provider Details

I. General information

NPI: 1538077730
Provider Name (Legal Business Name): KELLY LAZAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2026
Last Update Date: 08/29/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2455 MISSOURI AVE STE A
LAS CRUCES NM
88001-5122
US

IV. Provider business mailing address

9400 HOLLY AVE NE
ALBUQUERQUE NM
87122-2968
US

V. Phone/Fax

Practice location:
  • Phone: 505-336-0403
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: