Provider Demographics
NPI:1023320496
Name:LASTIE, SHELIA AMOS
Entity type:Individual
Prefix:
First Name:SHELIA
Middle Name:AMOS
Last Name:LASTIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:484 LAKE PARK AVE # 452
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-2730
Mailing Address - Country:US
Mailing Address - Phone:510-322-0137
Mailing Address - Fax:
Practice Address - Street 1:725 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-3924
Practice Address - Country:US
Practice Address - Phone:510-322-0137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT90474101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health