Provider Demographics
NPI:1003426545
Name:LASSLO, MATTHEW AARON
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:AARON
Last Name:LASSLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-0790
Mailing Address - Country:US
Mailing Address - Phone:928-645-5113
Mailing Address - Fax:928-645-3254
Practice Address - Street 1:463 S LAKE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040-0856
Practice Address - Country:US
Practice Address - Phone:928-645-5113
Practice Address - Fax:928-645-3254
Is Sole Proprietor?:No
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-17209101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor