Provider Demographics
NPI:1093443715
Name:ELY, LARA GABRIELLE
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:GABRIELLE
Last Name:ELY
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 1:4114 COZY PINE DR
Mailing Address - Street 2:
Mailing Address - City:NORTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76226-2722
Mailing Address - Country:US
Mailing Address - Phone:817-657-2106
Mailing Address - Fax:
Practice Address - Street 1:2400 N CARROLL AVE
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-3105
Practice Address - Country:US
Practice Address - Phone:817-949-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-10
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116742235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist