Provider Demographics
NPI:1588761225
Name:LAZARUS, MELINDA L (LCSW)
Entity type:Individual
Prefix:MS
First Name:MELINDA
Middle Name:L
Last Name:LAZARUS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MIXVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-1967
Mailing Address - Country:US
Mailing Address - Phone:203-651-9203
Mailing Address - Fax:
Practice Address - Street 1:53 CEDAR LAKE RD
Practice Address - Street 2:
Practice Address - City:NORTH BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06471
Practice Address - Country:US
Practice Address - Phone:203-651-9203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0030861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1942393814Medicaid
CT003086OtherLCSW LICENSE NUMBER
CT004161725Medicaid
CT800003652Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
CTC01762Medicare ID - Type UnspecifiedCMHA GOUP FACILITY #