Provider Demographics
NPI:1518563824
Name:LARA, VANESSA
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
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 1:2291 W MARCH LN STE C101
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6669
Mailing Address - Country:US
Mailing Address - Phone:209-662-4124
Mailing Address - Fax:
Practice Address - Street 1:2978 OLD RANCH CIR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-4833
Practice Address - Country:US
Practice Address - Phone:209-992-9501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician