Healthcare Provider Details

I. General information

NPI: 1396197786
Provider Name (Legal Business Name): MATTHEW LASLEY LMFT 109610
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2016
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 W 10TH ST
ANTIOCH CA
94509-1653
US

IV. Provider business mailing address

15 CASA VERDE WAY
PITTSBURG CA
94565-5707
US

V. Phone/Fax

Practice location:
  • Phone: 925-777-9540
  • Fax:
Mailing address:
  • Phone: 925-325-9056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number109610
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: