Provider Demographics
NPI:1689796245
Name:DASARO, LOIS NORTON (PHD)
Entity Type:Individual
Prefix:
First Name:LOIS
Middle Name:NORTON
Last Name:DASARO
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 1:1421 SANTA MONICA BLVD
Mailing Address - Street 2:#105
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1750
Mailing Address - Country:US
Mailing Address - Phone:310-394-9876
Mailing Address - Fax:310-823-3928
Practice Address - Street 1:1421 SANTA MONICA BLVD
Practice Address - Street 2:#105
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1750
Practice Address - Country:US
Practice Address - Phone:310-394-9876
Practice Address - Fax:310-823-3928
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4652103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP4652Medicare ID - Type Unspecified