Provider Demographics
NPI:1700425493
Name:LASTER, EBONY
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:LASTER
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 1:6792 HARRISON AVE APT 45
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-3219
Mailing Address - Country:US
Mailing Address - Phone:513-362-0052
Mailing Address - Fax:
Practice Address - Street 1:3268 JEFFERSON AVE # 1
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-2220
Practice Address - Country:US
Practice Address - Phone:513-362-0052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.023392225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist