Provider Demographics
NPI:1649571746
Name:LASTRA, MICHAEL II
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:LASTRA
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:LASTRA
Other - Suffix:II
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4505 TAFT AVE
Mailing Address - Street 2:4505 TAFT AVE.
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-3449
Mailing Address - Country:US
Mailing Address - Phone:510-235-3172
Mailing Address - Fax:
Practice Address - Street 1:4505 TAFT AVE
Practice Address - Street 2:4505 TAFT AVE.
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-3449
Practice Address - Country:US
Practice Address - Phone:510-235-3172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor