Provider Demographics
NPI:1336817683
Name:LASALA, OLIVIA (MA)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:LASALA
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 1:1426 WARSON OAKS CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-1660
Mailing Address - Country:US
Mailing Address - Phone:314-698-3155
Mailing Address - Fax:
Practice Address - Street 1:105 VICTORY RD
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-3518
Practice Address - Country:US
Practice Address - Phone:617-371-3010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral