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General NPI Number Information
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NPI Number | 1952614323
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Entity Type | Individual
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Provider Name | JONATHAN MATHIAS LASSITER PHD
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Gender | Male
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Dates
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Enumeration Date | 07/14/2010
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Last Update Date | 06/09/2021
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Provider Practice Location Address
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Address Line | 1133 BROADWAY STE 510
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City | NEW YORK
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State | NY
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Zip | 10010-8173
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Country | US
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Telephone | 347-498-3575
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Fax |
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Provider Business Mailing Address
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Address Line | 4312 WOODMONT CIR
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City | SEWELL
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State | NJ
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Zip | 08080-2285
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Country | US
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Telephone | 347-498-3575
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 022738
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License Number State | NY
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