Provider Demographics
NPI:1316088164
Name:LAZAR, GAYLE MARIE (MED)
Entity type:Individual
Prefix:MRS
First Name:GAYLE
Middle Name:MARIE
Last Name:LAZAR
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6530 N 44TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-4236
Mailing Address - Country:US
Mailing Address - Phone:623-842-8616
Mailing Address - Fax:623-842-1384
Practice Address - Street 1:4510 N 37TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85019-3206
Practice Address - Country:US
Practice Address - Phone:602-336-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-1761101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ572877Medicaid