Provider Demographics
NPI:1477515823
Name:LASSEN, KERRY (LCSW)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:LASSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 MESA DR
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:CT
Mailing Address - Zip Code:06524-3093
Mailing Address - Country:US
Mailing Address - Phone:203-641-6090
Mailing Address - Fax:
Practice Address - Street 1:2 TRAP FALLS RD STE 120
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484
Practice Address - Country:US
Practice Address - Phone:203-816-6424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0057071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT42-1643030OtherMULTIPLAN
CT004247088Medicaid
CT339452OtherMHN
CT140005707CT01OtherANTHEM