Provider Demographics
NPI:1861736811
Name:FASS, LARA FLEISCHAKER (BA, LMBT, LE)
Entity type:Individual
Prefix:MRS
First Name:LARA
Middle Name:FLEISCHAKER
Last Name:FASS
Suffix:
Gender:F
Credentials:BA, LMBT, LE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 DELBURG ST.
Mailing Address - Street 2:DAVIDSON
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036
Mailing Address - Country:US
Mailing Address - Phone:704-201-8653
Mailing Address - Fax:
Practice Address - Street 1:17039 KENTON DR. SUITE 104
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031
Practice Address - Country:US
Practice Address - Phone:704-896-2889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2158225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist