Provider Demographics
NPI:1730590480
Name:PASS, LAURENCE L (PSYD)
Entity type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:L
Last Name:PASS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:LAURENCE
Other - Middle Name:L
Other - Last Name:HAYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, MED
Mailing Address - Street 1:4175 S ALAMO AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIS-MONTHAN AFB
Mailing Address - State:AZ
Mailing Address - Zip Code:85707-4405
Mailing Address - Country:US
Mailing Address - Phone:520-228-2778
Mailing Address - Fax:
Practice Address - Street 1:307 BOATNER RD STE 114
Practice Address - Street 2:
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542-1302
Practice Address - Country:US
Practice Address - Phone:850-883-8374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-15
Last Update Date:2024-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60589535103TC0700X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist