Provider Demographics
NPI:1396043618
Name:LASSITER, JUDY DURRAH (MA)
Entity Type:Individual
Prefix:MS
First Name:JUDY
Middle Name:DURRAH
Last Name:LASSITER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 MIDDLEBURG DR
Mailing Address - Street 2:SUITE 206
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2415
Mailing Address - Country:US
Mailing Address - Phone:803-779-0354
Mailing Address - Fax:803-779-0119
Practice Address - Street 1:2712 MIDDLEBURG DR
Practice Address - Street 2:SUITE 206
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2415
Practice Address - Country:US
Practice Address - Phone:803-779-0354
Practice Address - Fax:803-779-0119
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC LPC 5254101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC582444986OtherPRIVATE INSURANCE