Provider Demographics
NPI:1114673274
Name:LASLEY, NATIEKA (QMHS 3YR)
Entity Type:Individual
Prefix:
First Name:NATIEKA
Middle Name:
Last Name:LASLEY
Suffix:
Gender:F
Credentials:QMHS 3YR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 W MONUMENT AVE FL 7
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-1274
Mailing Address - Country:US
Mailing Address - Phone:937-461-4300
Mailing Address - Fax:
Practice Address - Street 1:1535 WILLAMET RD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-4853
Practice Address - Country:US
Practice Address - Phone:937-461-4300
Practice Address - Fax:937-461-0443
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0301947Medicaid