Provider Demographics
NPI:1164774006
Name:LARA, MARIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:LARA
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 1:3752 ALICIA ST
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-4802
Mailing Address - Country:US
Mailing Address - Phone:909-524-2739
Mailing Address - Fax:
Practice Address - Street 1:8350 ARCHIBALD AVE STE 226
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3671
Practice Address - Country:US
Practice Address - Phone:909-276-4399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-02
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF79499106H00000X
CALMFT99474106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist