Provider Demographics
NPI:1225561103
Name:LARA T. SAN PEDRO, PSY.D., A PSYCHOLOGICAL CORPORATION
Entity Type:Organization
Organization Name:LARA T. SAN PEDRO, PSY.D., A PSYCHOLOGICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:LARA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAN PEDRO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:209-373-0884
Mailing Address - Street 1:39210 STATE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1456
Mailing Address - Country:US
Mailing Address - Phone:209-373-0884
Mailing Address - Fax:
Practice Address - Street 1:39210 STATE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1456
Practice Address - Country:US
Practice Address - Phone:209-373-0884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28229261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center