Provider Demographics
NPI:1629659610
Name:LARA WALDENMAIER LLC
Entity Type:Organization
Organization Name:LARA WALDENMAIER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFESSIONAL CLINICAL COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LARA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALDENMAIER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPCC
Authorized Official - Phone:440-525-6825
Mailing Address - Street 1:5900 SOM CENTER RD STE 12-203
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-3086
Mailing Address - Country:US
Mailing Address - Phone:440-540-5258
Mailing Address - Fax:
Practice Address - Street 1:5900 SOM CENTER RD STE 12-203
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-3086
Practice Address - Country:US
Practice Address - Phone:440-540-5258
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCS1625600131OtherCARESOURCE
OH0185639Medicaid
OH13815586OtherCAQH