Provider Demographics
NPI:1063535052
Name:LASEK, DANA G (PHD)
Entity type:Individual
Prefix:DR
First Name:DANA
Middle Name:G
Last Name:LASEK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11070 WINDING BROOK LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46280-1258
Mailing Address - Country:US
Mailing Address - Phone:317-502-1608
Mailing Address - Fax:
Practice Address - Street 1:420 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1364
Practice Address - Country:US
Practice Address - Phone:317-502-1608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041509A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN00000050018OtherANTHEM BLUE CROSS BLUE SH