Provider Demographics
NPI:1881335628
Name:LAZARUS, CARLY TARA
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:TARA
Last Name:LAZARUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 KINROSS RD
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-7201
Mailing Address - Country:US
Mailing Address - Phone:781-408-2168
Mailing Address - Fax:
Practice Address - Street 1:11 KINROSS RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-7201
Practice Address - Country:US
Practice Address - Phone:781-408-2168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician