Provider Demographics
NPI:1407217045
Name:LASLEY, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:LASLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2703 HOWELL TRCE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-7974
Mailing Address - Country:US
Mailing Address - Phone:404-808-4840
Mailing Address - Fax:
Practice Address - Street 1:2703 HOWELL TRCE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-7974
Practice Address - Country:US
Practice Address - Phone:404-808-4840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral