Healthcare Provider Details

I. General information

NPI: 1306859202
Provider Name (Legal Business Name): MILTON LASOSKI PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4253 MONTGOMERY BLVD NE STE 220
ALBUQUERQUE NM
87109-1106
US

IV. Provider business mailing address

4253 MONTGOMERY BLVD NE STE 220
ALBUQUERQUE NM
87109-1106
US

V. Phone/Fax

Practice location:
  • Phone: 505-342-0400
  • Fax:
Mailing address:
  • Phone: 505-342-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number364
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: