Provider Demographics
NPI:1508342890
Name:LARA, EILEEN ISAMAR
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:ISAMAR
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 1:18 ALGONQUIN ST APT 5
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-1150
Mailing Address - Country:US
Mailing Address - Phone:617-293-0418
Mailing Address - Fax:
Practice Address - Street 1:30 WARREN ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3680
Practice Address - Country:US
Practice Address - Phone:617-293-0418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker