Provider Demographics
NPI:1003336520
Name:QUESADA, LARA
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:QUESADA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 5TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-4332
Mailing Address - Country:US
Mailing Address - Phone:813-503-4840
Mailing Address - Fax:
Practice Address - Street 1:4555 S MANHATTAN AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-2305
Practice Address - Country:US
Practice Address - Phone:813-839-6341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA15448235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist