Provider Demographics
NPI:1629577358
Name:LAZZARO, KATHLEEN (EDS)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:LAZZARO
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 S NANSEMOND ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23221-3647
Mailing Address - Country:US
Mailing Address - Phone:914-584-7349
Mailing Address - Fax:
Practice Address - Street 1:2401 HARTMAN ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-2458
Practice Address - Country:US
Practice Address - Phone:804-343-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0813000660Medicaid