Healthcare Provider Details

I. General information

NPI: 1528404654
Provider Name (Legal Business Name): MICHAEL GLEN LASTER LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2013
Last Update Date: 06/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 EAST AVE
AUSTIN TX
78701-4323
US

IV. Provider business mailing address

1430 COLLIER ST
AUSTIN TX
78704-2911
US

V. Phone/Fax

Practice location:
  • Phone: 512-703-1312
  • Fax: 512-703-1390
Mailing address:
  • Phone: 512-445-7787
  • Fax: 512-440-4059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number60323
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: