Healthcare Provider Details

I. General information

NPI: 1548996887
Provider Name (Legal Business Name): TRACEY LAZORE MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2022
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 MAIN ST
CAMDEN NY
13316-1302
US

IV. Provider business mailing address

1759 NEWPORT RD
POLAND NY
13431-1708
US

V. Phone/Fax

Practice location:
  • Phone: 315-533-2570
  • Fax:
Mailing address:
  • Phone: 315-867-3219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP116333
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: