Provider Demographics
NPI:1033426481
Name:LARA, LATICIA
Entity Type:Individual
Prefix:
First Name:LATICIA
Middle Name:
Last Name:LARA
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 1:609 PROSPECT AVE
Mailing Address - Street 2:APT.#8
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-2454
Mailing Address - Country:US
Mailing Address - Phone:323-459-7131
Mailing Address - Fax:
Practice Address - Street 1:3250 WILSHIRE BLVD
Practice Address - Street 2:5TH FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-1577
Practice Address - Country:US
Practice Address - Phone:323-361-3849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-07
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker