Provider Demographics
NPI:1265821466
Name:TAYLOR, LARA (BCBA)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:
Other - Last Name:PEAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12126 MUSTANG AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIS
Mailing Address - State:TX
Mailing Address - Zip Code:77378-4940
Mailing Address - Country:US
Mailing Address - Phone:832-724-1319
Mailing Address - Fax:
Practice Address - Street 1:12126 MUSTANG AVE
Practice Address - Street 2:
Practice Address - City:WILLIS
Practice Address - State:TX
Practice Address - Zip Code:77378-4940
Practice Address - Country:US
Practice Address - Phone:832-724-1319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBACB231829103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst