Provider Demographics
NPI:1174651095
Name:LARA, RICHARD BRANNEN (LMSW)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:BRANNEN
Last Name:LARA
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 HUNTER ST
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2655
Mailing Address - Country:US
Mailing Address - Phone:505-753-4123
Mailing Address - Fax:505-753-6947
Practice Address - Street 1:404 HUNTER ST
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2655
Practice Address - Country:US
Practice Address - Phone:505-753-4123
Practice Address - Fax:505-753-6947
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX05752104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME7436Medicaid