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General NPI Number Information
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NPI Number | 1720358534
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Entity Type | Individual
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Provider Name | LAZAR KIZHAKEDAN LSW, CADC
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Gender | Male
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Dates
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Enumeration Date | 01/10/2012
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Last Update Date | 01/10/2012
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Provider Practice Location Address
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Address Line | 3033 W JEFFERSON ST SUITE 205
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City | JOLIET
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State | IL
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Zip | 60435-5261
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Country | US
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Telephone | 815-773-6277
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Fax |
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Provider Business Mailing Address
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Address Line | 3 H WILDWOOD LN
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City | BOLINGBROOK
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State | IL
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Zip | 60440-1943
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 29480
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 150.012857
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License Number State | IL
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