Provider Demographics
NPI:1588066831
Name:LASSALLY, AMBER J (LGSW)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:J
Last Name:LASSALLY
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1298 BAY DALE DR
Mailing Address - Street 2:SUITE 211
Mailing Address - City:ARNOLD
Mailing Address - State:MD
Mailing Address - Zip Code:21012-2804
Mailing Address - Country:US
Mailing Address - Phone:410-919-4904
Mailing Address - Fax:
Practice Address - Street 1:1298 BAY DALE DR
Practice Address - Street 2:SUITE 211
Practice Address - City:ARNOLD
Practice Address - State:MD
Practice Address - Zip Code:21012-2804
Practice Address - Country:US
Practice Address - Phone:410-919-4904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22010104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker