Provider Demographics
NPI:1114439098
Name:DAVIS, LARA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LARA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:LARA
Other - Middle Name:
Other - Last Name:HERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:505 N PARK AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-3268
Mailing Address - Country:US
Mailing Address - Phone:407-641-1431
Mailing Address - Fax:
Practice Address - Street 1:505 N PARK AVE STE 201
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-3268
Practice Address - Country:US
Practice Address - Phone:407-641-1431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9916103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical