Provider Demographics
NPI:1275687725
Name:LASSEN, MAUREEN (PHD)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:LASSEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 S POWER RD
Mailing Address - Street 2:SUITE 254
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-3700
Mailing Address - Country:US
Mailing Address - Phone:480-785-0525
Mailing Address - Fax:480-656-4528
Practice Address - Street 1:1234 S POWER RD
Practice Address - Street 2:SUITE 254
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-3700
Practice Address - Country:US
Practice Address - Phone:480-785-0525
Practice Address - Fax:480-656-4528
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ691103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ144769Medicare PIN
Z21450Medicare ID - Type Unspecified