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General NPI Number Information
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NPI Number | 1629689922
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Entity Type | Organization
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Legal Business Name | CEREBRO WELLNESS
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Dates
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Enumeration Date | 08/11/2020
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Last Update Date | 11/10/2023
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Provider Practice Location Address
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Address Line | 2111 E BASELINE RD STE F4
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City | TEMPE
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State | AZ
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Zip | 85283-1519
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Country | US
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Telephone | 602-888-3474
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Fax | 762-212-4347
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Provider Business Mailing Address
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Address Line | 5223 1/2 S 5TH ST
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City | PHOENIX
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State | AZ
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Zip | 85040-8707
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Country | US
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Telephone | 602-904-2277
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. BRYAN KEOKE LAZARO
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Credential | PMHNP
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Telephone | 602-904-2277
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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