Provider Demographics
NPI:1902074982
Name:DUSANTOS, LAURENCIA CDL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LAURENCIA
Middle Name:CDL
Last Name:DUSANTOS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 PRINCESS ANNE ST STE 402
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-5804
Mailing Address - Country:US
Mailing Address - Phone:405-322-2289
Mailing Address - Fax:540-479-3282
Practice Address - Street 1:904 PRINCESS ANNE ST STE 402
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-5804
Practice Address - Country:US
Practice Address - Phone:785-375-0375
Practice Address - Fax:785-375-0375
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-13
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005067103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD58956180Medicaid
MD941L70Medicare UPIN