MEDICARE: DR. ASHLEY FOGARTY LASS PSY.D, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PY7188	FL

General Provider Information

NPI Number	:	1841241569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ASHLEY FOGARTY LASS PSY.D, P.A.

Provider Business Mailing Address
First Line	:	3616 W ROLAND ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-2832
Country	:	US
Telephone Number	:	813-789-3709
Fax Number	:

Provider Business Practice Location Address
First Line	:	2425 E HANNA AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33610-1317
Country	:	US
Telephone Number	:	813-238-3053
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2006
Last Update Date	:	07/08/2007

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