Provider Demographics
NPI:1568033629
Name:LARA, GLADYS (DN)
Entity Type:Individual
Prefix:DR
First Name:GLADYS
Middle Name:
Last Name:LARA
Suffix:
Gender:F
Credentials:DN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4107 W BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-4617
Mailing Address - Country:US
Mailing Address - Phone:773-710-9457
Mailing Address - Fax:
Practice Address - Street 1:4107 W BELMONT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-4617
Practice Address - Country:US
Practice Address - Phone:773-710-9457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172P00000X, 225700000X
IL181.000406174400000X, 204C00000X, 208100000X, 172P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172P00000XOther Service ProvidersNaprapath
No174400000XOther Service ProvidersSpecialist
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist