Provider Demographics
NPI:1336643386
Name:LASSITER, AILEEN IMANA
Entity Type:Individual
Prefix:
First Name:AILEEN
Middle Name:IMANA
Last Name:LASSITER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1462 CHERRY ST APT 121
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-5888
Mailing Address - Country:US
Mailing Address - Phone:336-695-9188
Mailing Address - Fax:
Practice Address - Street 1:1462 CHERRY ST APT 121
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-5888
Practice Address - Country:US
Practice Address - Phone:336-695-9188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-22
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA13646101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional