Provider Demographics
NPI:1629310511
Name:LASTER, DORENE (MA)
Entity Type:Individual
Prefix:MS
First Name:DORENE
Middle Name:
Last Name:LASTER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7120 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-3002
Mailing Address - Country:US
Mailing Address - Phone:323-876-0550
Mailing Address - Fax:323-436-7044
Practice Address - Street 1:7120 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90046-3002
Practice Address - Country:US
Practice Address - Phone:323-876-0550
Practice Address - Fax:323-436-7044
Is Sole Proprietor?:No
Enumeration Date:2013-03-19
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CAIMF 59207106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist