Provider Demographics
NPI:1568126670
Name:ULMER, LARA CARCOURA
Entity Type:Individual
Prefix:MRS
First Name:LARA
Middle Name:CARCOURA
Last Name:ULMER
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 1:1100 EUCLID AVE APT 105
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-4051
Mailing Address - Country:US
Mailing Address - Phone:562-362-1196
Mailing Address - Fax:
Practice Address - Street 1:1100 EUCLID AVE APT 105
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-4051
Practice Address - Country:US
Practice Address - Phone:562-362-1196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool