Provider Demographics
NPI:1376085126
Name:DASTA, LAURA (LMT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:DASTA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8162 COUNTRY RD
Mailing Address - Street 2:UNIT 206
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-7142
Mailing Address - Country:US
Mailing Address - Phone:239-851-3710
Mailing Address - Fax:
Practice Address - Street 1:2242 PERIWINKLE WAY
Practice Address - Street 2:SUITE 2
Practice Address - City:SANIBEL
Practice Address - State:FL
Practice Address - Zip Code:33957-4010
Practice Address - Country:US
Practice Address - Phone:239-395-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA59019225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist