=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215801253
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID LASUERTMER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2025
-----------------------------------------------------
Last Update Date | 10/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 W KIRKWOOD AVE STE 140
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47404-6132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-490-1250
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4501 E STREACHER RD
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47408-9790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-490-1250
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 34012148A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------