Provider Demographics
NPI:1578765939
Name:LASTER, MARK (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:LASTER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6515 ALDERTON ST
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-5052
Mailing Address - Country:US
Mailing Address - Phone:646-515-9083
Mailing Address - Fax:
Practice Address - Street 1:6515 ALDERTON ST
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-5052
Practice Address - Country:US
Practice Address - Phone:646-515-9083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0265621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02013674Medicaid
NY02013674Medicaid
NY01622Medicare ID - Type UnspecifiedQUEENS MEDICARE PART B
NYN99632Medicare ID - Type UnspecifiedMEDICARE PART B