Provider Demographics
NPI:1407987217
Name:LARA, MARTIN J (MACC, LISAC, ALPC, P)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:J
Last Name:LARA
Suffix:
Gender:M
Credentials:MACC, LISAC, ALPC, P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2517 E COUNTY 16TH ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85365-9214
Mailing Address - Country:US
Mailing Address - Phone:928-317-3157
Mailing Address - Fax:
Practice Address - Street 1:1453 N MAIN ST. SUITE F
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349
Practice Address - Country:US
Practice Address - Phone:928-627-6567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ884496OtherAHCCCS