Provider Demographics
NPI:1093305856
Name:IANNACCONE, LARA JEAN
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:JEAN
Last Name:IANNACCONE
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 1:5803 FRESH MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:MACUNGIE
Mailing Address - State:PA
Mailing Address - Zip Code:18062-9588
Mailing Address - Country:US
Mailing Address - Phone:484-357-2105
Mailing Address - Fax:
Practice Address - Street 1:2015 HAMILTON ST STE 203
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-6471
Practice Address - Country:US
Practice Address - Phone:484-274-6895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA135501101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health