Healthcare Provider Details

I. General information

NPI: 1114673274
Provider Name (Legal Business Name): NATIEKA LASLEY QMHS 3YR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2022
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 WILLAMET RD
KETTERING OH
45429-4853
US

IV. Provider business mailing address

11 W MONUMENT AVE FL 7
DAYTON OH
45402-1274
US

V. Phone/Fax

Practice location:
  • Phone: 937-461-4300
  • Fax: 937-461-0443
Mailing address:
  • Phone: 937-461-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: