Provider Demographics
NPI:1346324837
Name:WENTWORTH, LARA ELIZABETH (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:ELIZABETH
Last Name:WENTWORTH
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7303 WILD OLIVE AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-2079
Mailing Address - Country:US
Mailing Address - Phone:505-888-4469
Mailing Address - Fax:
Practice Address - Street 1:3530 PAN AMERICAN FWY NE STE D
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4793
Practice Address - Country:US
Practice Address - Phone:505-888-4469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2218235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist