Healthcare Provider Details

I. General information

NPI: 1538689302
Provider Name (Legal Business Name): DARA MICHELLE LAZAR LICENSED MASSAGE THE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14-17 31ST AVENUE APT 2B
ASTORIA NY
11106
US

IV. Provider business mailing address

14-17 31ST AVENUE APT 2B
ASTORIA NY
11106
US

V. Phone/Fax

Practice location:
  • Phone: 347-218-1641
  • Fax:
Mailing address:
  • Phone: 347-218-1641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number018746
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: