Provider Demographics
NPI:1952042293
Name:LAWRENCE, NASTASSJA
Entity Type:Individual
Prefix:
First Name:NASTASSJA
Middle Name:
Last Name:LAWRENCE
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 1:5155 S TORREY PINES DR APT 2150
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-0648
Mailing Address - Country:US
Mailing Address - Phone:626-404-8471
Mailing Address - Fax:
Practice Address - Street 1:5155 S TORREY PINES DR APT 2150
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-0648
Practice Address - Country:US
Practice Address - Phone:626-404-8471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-01
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20222408600320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness