Provider Demographics
NPI:1568141802
Name:LARA, CITLALI MARIELI
Entity Type:Individual
Prefix:
First Name:CITLALI
Middle Name:MARIELI
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 1:1440 W TAYLOR ST # 2059
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4623
Mailing Address - Country:US
Mailing Address - Phone:630-770-7469
Mailing Address - Fax:
Practice Address - Street 1:555 N ASHBURY AVE
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1269
Practice Address - Country:US
Practice Address - Phone:630-770-7469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-13
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL108592104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker