Provider Demographics
NPI:1356561625
Name:LASLOVICH, TANIA A (ATC)
Entity type:Individual
Prefix:
First Name:TANIA
Middle Name:A
Last Name:LASLOVICH
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:TANIA
Other - Middle Name:A
Other - Last Name:DMITRI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:PO BOX 4012
Mailing Address - Street 2:
Mailing Address - City:VINEYARD HAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02568-0928
Mailing Address - Country:US
Mailing Address - Phone:508-693-1033
Mailing Address - Fax:
Practice Address - Street 1:100 EDGARTOWN ROAD
Practice Address - Street 2:
Practice Address - City:OAK BLUFFS
Practice Address - State:MA
Practice Address - Zip Code:02557
Practice Address - Country:US
Practice Address - Phone:508-693-1033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17422255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA960212OtherNATA MEMBER DISTRICT 1
MA1742OtherMA AHP LICENSE