Healthcare Provider Details

I. General information

NPI: 1730395161
Provider Name (Legal Business Name): JEFFREY LAZOVIK LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 COUNTY ROUTE 17
DE KALB JUNCTION NY
13630-3158
US

IV. Provider business mailing address

4120 COUNTY ROUTE 17
DE KALB JUNCTION NY
13630-3158
US

V. Phone/Fax

Practice location:
  • Phone: 315-347-4068
  • Fax: 315-347-4068
Mailing address:
  • Phone: 315-347-4068
  • Fax: 315-347-4068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number000343-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: