Provider Demographics
NPI:1053491225
Name:FREDA, LARA ANN (EDS SCHOOL PSYCH)
Entity Type:Individual
Prefix:MISS
First Name:LARA
Middle Name:ANN
Last Name:FREDA
Suffix:
Gender:F
Credentials:EDS SCHOOL PSYCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16429 S 33RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7845
Mailing Address - Country:US
Mailing Address - Phone:623-478-4239
Mailing Address - Fax:
Practice Address - Street 1:9419 W VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-2804
Practice Address - Country:US
Practice Address - Phone:623-478-4239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
CA103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ099101Medicaid