Provider Demographics
NPI:1578753950
Name:LARA, ELISA (CADC-CAS)
Entity Type:Individual
Prefix:MISS
First Name:ELISA
Middle Name:
Last Name:LARA
Suffix:
Gender:F
Credentials:CADC-CAS
Other - Prefix:
Other - First Name:ELISA
Other - Middle Name:
Other - Last Name:LARA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CAS
Mailing Address - Street 1:PO BOX 2087
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95344-0087
Mailing Address - Country:US
Mailing Address - Phone:209-381-6800
Mailing Address - Fax:209-385-3174
Practice Address - Street 1:40 W G ST STE C
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-3657
Practice Address - Country:US
Practice Address - Phone:209-710-6100
Practice Address - Fax:209-827-2009
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-31
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC13861214101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)