MEDICARE: DR. KENNETH CHRISTOPHER LAZZARA PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	6301010699	MI
2	103T00000X	Psychologist	PY11760	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	680F333500	OTHER	MI	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1780820886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH CHRISTOPHER LAZZARA PHD

Provider Business Mailing Address
First Line	:	9160 FORUM CORPORATE PKWY STE 350
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33905-7808
Country	:	US
Telephone Number	:	239-391-7313
Fax Number	:

Provider Business Practice Location Address
First Line	:	9160 FORUM CORPORATE PKWY STE 350
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33905-7808
Country	:	US
Telephone Number	:	239-391-7313
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2008
Last Update Date	:	03/07/2023

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