MEDICARE: MARCUS LASOTA PH.D.

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	PSY1000652	DC

General Provider Information

NPI Number	:	1104372069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARCUS LASOTA PH.D.

Provider Business Mailing Address
First Line	:	4001 HAREWOOD RD NE
Second Line	:	110 O'BOYLE HALL
City	:	WASHINGTON
State	:	DC
Zip	:	20017-1508
Country	:	US
Telephone Number	:	702-232-2774
Fax Number	:

Provider Business Practice Location Address
First Line	:	4001 HAREWOOD RD NE
Second Line	:	110 O'BOYLE HALL
City	:	WASHINGTON
State	:	DC
Zip	:	20017-1508
Country	:	US
Telephone Number	:	702-232-2774
Fax Number	:

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

Provider Enumeration Date	:	08/31/2016
Last Update Date	:	08/31/2016

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