Provider Demographics
NPI:1649392069
Name:LASECKI, TERRA DOVE (DEVELOPMENTAL THERAP)
Entity Type:Individual
Prefix:MRS
First Name:TERRA
Middle Name:DOVE
Last Name:LASECKI
Suffix:
Gender:F
Credentials:DEVELOPMENTAL THERAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 CUMBERLAND AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-1343
Mailing Address - Country:US
Mailing Address - Phone:812-841-7130
Mailing Address - Fax:
Practice Address - Street 1:1305 CUMBERLAND AVE STE 225
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1343
Practice Address - Country:US
Practice Address - Phone:812-841-7130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-05
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200732240Medicaid
IN200732240OtherDEVELOPMENTAL THERAPIST