Provider Demographics
NPI:1285856724
Name:LASSITER, KIM DUDLEY (PHD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:DUDLEY
Last Name:LASSITER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6 DOVE DRIVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-3366
Mailing Address - Country:US
Mailing Address - Phone:740-597-1251
Mailing Address - Fax:740-593-4790
Practice Address - Street 1:OHIO UNIVERSITY DEPARTMENT OF PSYCHOLOGY
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-2979
Practice Address - Country:US
Practice Address - Phone:740-597-1251
Practice Address - Fax:740-593-4790
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4603103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical