Provider Demographics
NPI:1285179952
Name:ACIKBAHT, LARA
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:ACIKBAHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:
Other - Last Name:FIDALGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:610 VALLEY HEALTH PLZ
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-3607
Mailing Address - Country:US
Mailing Address - Phone:201-797-2660
Mailing Address - Fax:
Practice Address - Street 1:17-07 ROMAINE ST
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-2150
Practice Address - Country:US
Practice Address - Phone:201-797-2660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00212900101Y00000X
NJ37PC00598800101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor