Provider Demographics
NPI:1346474137
Name:LARA, VIVIAN MARITZA
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:MARITZA
Last Name:LARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 SW 19TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145-2648
Mailing Address - Country:US
Mailing Address - Phone:786-232-5640
Mailing Address - Fax:305-285-9825
Practice Address - Street 1:2110 SW 19TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-2648
Practice Address - Country:US
Practice Address - Phone:786-232-5640
Practice Address - Fax:305-285-9825
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT12214225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist