Provider Demographics
NPI:1174842967
Name:LASTORIA, MICHAEL (EDD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:LASTORIA
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 OLD ENGLISH DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14616-1952
Mailing Address - Country:US
Mailing Address - Phone:585-808-5370
Mailing Address - Fax:
Practice Address - Street 1:194 OLD ENGLISH DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14616-1952
Practice Address - Country:US
Practice Address - Phone:585-808-5370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-19
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000168106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist