Healthcare Provider Details

I. General information

NPI: 1700229564
Provider Name (Legal Business Name): LAZRIA PRICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 04/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 W CAPITOL DR
MILWAUKEE WI
53216-2530
US

IV. Provider business mailing address

4001 W CAPITOL DR
MILWAUKEE WI
53216-2530
US

V. Phone/Fax

Practice location:
  • Phone: 414-455-3879
  • Fax:
Mailing address:
  • Phone: 414-759-6377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number16859
License Number StateWI

VIII. Authorized Official

Name: LAZRIA TRINETTE PRICE
Title or Position: SAC-IT
Credential:
Phone: 262-497-3445