Provider Demographics
NPI:1548996887
Name:LAZORE, TRACEY (MSW)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:LAZORE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1759 NEWPORT RD
Mailing Address - Street 2:
Mailing Address - City:POLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13431-1708
Mailing Address - Country:US
Mailing Address - Phone:315-867-3219
Mailing Address - Fax:
Practice Address - Street 1:40 MAIN ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NY
Practice Address - Zip Code:13316-1302
Practice Address - Country:US
Practice Address - Phone:315-533-2570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP1163331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP116333OtherLIMITED PERMIT