Provider Demographics
NPI:1760709778
Name:FAASSEN, MENZO LEE (LPCC)
Entity Type:Individual
Prefix:MR
First Name:MENZO
Middle Name:LEE
Last Name:FAASSEN
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 SEMMES AVE APT 411
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-2184
Mailing Address - Country:US
Mailing Address - Phone:615-734-9969
Mailing Address - Fax:
Practice Address - Street 1:7702 E PARHAM RD STE 205
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23294-4374
Practice Address - Country:US
Practice Address - Phone:804-747-5674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCMH0201241101YM0800X
VA0701010945101YM0800X
TN3360101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0701010945OtherLPCC
TN3360OtherSTATE OF TN LICENSURE
NMCCMH0201241OtherSTATE OF NM
TNQ016677Medicaid
TNQ025738Medicaid
TNQ013774Medicaid