Provider Demographics
NPI:1881004174
Name:LASTER, TELISHA (LMT)
Entity Type:Individual
Prefix:
First Name:TELISHA
Middle Name:
Last Name:LASTER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2824 E 120TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-2122
Mailing Address - Country:US
Mailing Address - Phone:216-835-4742
Mailing Address - Fax:
Practice Address - Street 1:14077 CEDAR RD
Practice Address - Street 2:LL8
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44118-3338
Practice Address - Country:US
Practice Address - Phone:216-321-1141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-07
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.018721-L-M225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist