Basic Information
| Provider Information | |||||||||
| NPI: | 1356550560 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVID | ||||||||
| FirstName: | ALTHEA | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LAZZARA | ||||||||
| OtherFirstName: | ALTHEA | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PSYD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1135 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | CLIFTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070133346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882445373 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1135 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | CLIFTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070133346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882445373 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 35S100442900 | NJ | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.