Healthcare Provider Details

I. General information

NPI: 1205048006
Provider Name (Legal Business Name): BETH LAZARUS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21704 NORTHERN BLVD SUITE 29
BAYSIDE NY
11361-3500
US

IV. Provider business mailing address

217-04 NORTHERN BLVD SUITE 29
BAYSIDE NY
11361
US

V. Phone/Fax

Practice location:
  • Phone: 718-423-7371
  • Fax:
Mailing address:
  • Phone: 718-423-7371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR0211921
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: