Provider Demographics
NPI:1053771618
Name:LASSITER, AMY LYNN (PTA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:LASSITER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6657 EL MAR DR NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-6505
Mailing Address - Country:US
Mailing Address - Phone:330-715-6825
Mailing Address - Fax:
Practice Address - Street 1:3625 MARSH RD
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-5823
Practice Address - Country:US
Practice Address - Phone:330-346-0060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA.10119225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant