Provider Demographics
NPI:1932202314
Name:NASTAS, LAURIE SUE (CCCA)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:SUE
Last Name:NASTAS
Suffix:
Gender:F
Credentials:CCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14600 KING RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-7952
Mailing Address - Country:US
Mailing Address - Phone:734-486-4444
Mailing Address - Fax:734-486-5555
Practice Address - Street 1:14600 KING RD
Practice Address - Street 2:SUITE D
Practice Address - City:RIVERVIEW
Practice Address - State:MI
Practice Address - Zip Code:48193-7952
Practice Address - Country:US
Practice Address - Phone:734-486-4444
Practice Address - Fax:734-486-5555
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000272231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4189127Medicaid
MI540H001354OtherBCBSM
5352130OtherAETNA HMO AND MC
MI640H977751OtherBCBSM
5352130OtherAETNA HMO AND MC
MI4189127Medicaid