Provider Demographics
NPI:1215546841
Name:LASTER, MICHELLE KELLI
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:KELLI
Last Name:LASTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:KELLI
Other - Last Name:RIDLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:608 JACKSON ST STE 108
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-2600
Mailing Address - Country:US
Mailing Address - Phone:252-541-4175
Mailing Address - Fax:252-541-4245
Practice Address - Street 1:608 JACKSON ST STE 108
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-2600
Practice Address - Country:US
Practice Address - Phone:252-541-4175
Practice Address - Fax:252-541-4245
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)