Provider Demographics
NPI:1114599297
Name:LASTER, KRISTY WAGNER (LPC)
Entity Type:Individual
Prefix:DR
First Name:KRISTY
Middle Name:WAGNER
Last Name:LASTER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 LAKELAND DR STE 504
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-8854
Mailing Address - Country:US
Mailing Address - Phone:769-208-5120
Mailing Address - Fax:
Practice Address - Street 1:3900 LAKELAND DR STE 504
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-8854
Practice Address - Country:US
Practice Address - Phone:769-208-5120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2675101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional