Basic Information
| Provider Information | |||||||||
| NPI: | 1992932560 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LASETER | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 290 MOYER LN. NW | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034852197 | ||||||||
| FaxNumber: | 5033634214 | ||||||||
| Practice Location | |||||||||
| Address1: | 290 MOYER LN. NW | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034852197 | ||||||||
| FaxNumber: | 5033634214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2009 | ||||||||
| LastUpdateDate: | 06/22/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 039714 | 05 | OR | MEDICAID |