Basic Information
| Provider Information | |||||||||
| NPI: | 1982260519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LASATER | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | CAMILLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PIERCE | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | CAMILLE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 433 SHELTON LN | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422767600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709015000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2010 W 12TH ST | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324011850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507474565 | ||||||||
| FaxNumber: | 8507475317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2019 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 256962 | KY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | SW8350 | FL | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.