MEDICARE: LISA LASATER PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TB0200X	Cognitive & Behavioral Psychologist	2-5825	TX
2	103TC0700X	Clinical Psychologist	2-5825	TX
3	103TC1900X	Counseling Psychologist	2-5825	TX
4	103TC2200X	Clinical Child & Adolescent Psychologist	2-5825	TX

General Provider Information

NPI Number	:	1841558384
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA LASATER PH.D.

Provider Business Mailing Address
First Line	:	1509 W NORTH LOOP BLVD
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78756-2004
Country	:	US
Telephone Number	:	512-524-5482
Fax Number	:	512-524-1177

Provider Business Practice Location Address
First Line	:	1509 W NORTH LOOP BLVD
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78756-2004
Country	:	US
Telephone Number	:	512-524-5482
Fax Number	:	512-524-1177

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2012
Last Update Date	:	05/02/2012

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