Provider Demographics
NPI:1063846764
Name:LARA, BENJAMIN RAMON (LMSW)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:RAMON
Last Name:LARA
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5859 MILLWRIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83714-1665
Mailing Address - Country:US
Mailing Address - Phone:208-433-0400
Mailing Address - Fax:208-433-5271
Practice Address - Street 1:9196 W BARNES DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1552
Practice Address - Country:US
Practice Address - Phone:208-433-0400
Practice Address - Fax:208-433-5271
Is Sole Proprietor?:No
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID32322104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker