=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891260485
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAZZARO PSYCHOLOGICAL SERVICES, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2018
-----------------------------------------------------
Last Update Date | 10/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 36 MAIN ST STE 105
-----------------------------------------------------
City | PARK RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60068-4059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-712-1445
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36 MAIN ST STE 105
-----------------------------------------------------
City | PARK RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60068-4059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-712-1445
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER - CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. BRIAN RICHARD LAZZARO
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 847-712-1445
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------