Provider Demographics
NPI:1396350328
Name:WEBSTER, LAKRYSTA
Entity type:Individual
Prefix:
First Name:LAKRYSTA
Middle Name:
Last Name:WEBSTER
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 1:4530 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-3345
Mailing Address - Country:US
Mailing Address - Phone:937-321-0449
Mailing Address - Fax:
Practice Address - Street 1:4530 KINGS HWY
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-3345
Practice Address - Country:US
Practice Address - Phone:937-321-0449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA173575101YA0400X
OHRU386424172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)