Provider Demographics
NPI:1164655247
Name:LARA, HECTOR (MSW)
Entity Type:Individual
Prefix:MR
First Name:HECTOR
Middle Name:
Last Name:LARA
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16170 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LOWER LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95457
Mailing Address - Country:US
Mailing Address - Phone:707-272-8707
Mailing Address - Fax:707-995-1847
Practice Address - Street 1:14130 LAKESHORE DR.
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422
Practice Address - Country:US
Practice Address - Phone:707-272-8707
Practice Address - Fax:707-995-1847
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 104100000X
CA29325101Y00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker