Provider Demographics
NPI:1437409760
Name:LASTER, TONYA RENEE (MFTI)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:RENEE
Last Name:LASTER
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 TULLY RD
Mailing Address - Street 2:SUITE A-2
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-2946
Mailing Address - Country:US
Mailing Address - Phone:209-622-1420
Mailing Address - Fax:
Practice Address - Street 1:1800 TULLY RD
Practice Address - Street 2:SUITE A-2
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-2946
Practice Address - Country:US
Practice Address - Phone:209-622-1420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75935106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist