Provider Demographics
NPI:1922848589
Name:ROSS, LASONJA RENA (LICSW-S, PIP)
Entity type:Individual
Prefix:
First Name:LASONJA
Middle Name:RENA
Last Name:ROSS
Suffix:
Gender:F
Credentials:LICSW-S, PIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:MILLBROOK
Mailing Address - State:AL
Mailing Address - Zip Code:36054-0002
Mailing Address - Country:US
Mailing Address - Phone:334-294-9709
Mailing Address - Fax:
Practice Address - Street 1:140 EAGLE ROCK BND
Practice Address - Street 2:
Practice Address - City:MILLBROOK
Practice Address - State:AL
Practice Address - Zip Code:36054-1779
Practice Address - Country:US
Practice Address - Phone:334-652-3337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4382C-S1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical