Provider Demographics
NPI:1508158221
Name:CLEARY, LARA JULIANNE
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:JULIANNE
Last Name:CLEARY
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 1:626 CORDOVA ST STE 104
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99501-3783
Mailing Address - Country:US
Mailing Address - Phone:907-375-0930
Mailing Address - Fax:
Practice Address - Street 1:626 CORDOVA ST STE 104
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-3783
Practice Address - Country:US
Practice Address - Phone:907-375-0930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-13
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1482225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist