Provider Demographics
NPI:1346011756
Name:LASS, LESLIE JANE (PHD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:JANE
Last Name:LASS
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 1:36236 CORONADO DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-5535
Mailing Address - Country:US
Mailing Address - Phone:202-812-6755
Mailing Address - Fax:
Practice Address - Street 1:638 INDEPENDENCE PKWY STE 240
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-5222
Practice Address - Country:US
Practice Address - Phone:202-812-7655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09030033981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical