Basic Information
| Provider Information | |||||||||
| NPI: | 1558671982 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LASORSA | ||||||||
| FirstName: | DOMINICK CARL | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MS, LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 480 GALLETTI WAY | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894315564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7756882001 | ||||||||
| FaxNumber: | 7756882004 | ||||||||
| Practice Location | |||||||||
| Address1: | 480 GALLETTI WAY | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894315564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7756882001 | ||||||||
| FaxNumber: | 7756882004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2010 | ||||||||
| LastUpdateDate: | 01/14/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255R0406X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Rehabilitation, Blind | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 7753484894 | 01 | NV | HOME PHONE | OTHER |