Provider Demographics
NPI:1407400153
Name:BURT, LARA
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:BURT
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 1:1801 MISSISSIPPI AVE SE FL 3
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-6120
Mailing Address - Country:US
Mailing Address - Phone:847-644-4987
Mailing Address - Fax:
Practice Address - Street 1:1801 MISSISSIPPI AVE SE FL 3
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-6120
Practice Address - Country:US
Practice Address - Phone:847-644-4987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLG500826471041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool