Provider Demographics
NPI:1659679470
Name:LARA, ILSIA SONALI (MA)
Entity Type:Individual
Prefix:MS
First Name:ILSIA
Middle Name:SONALI
Last Name:LARA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 CALLE DAKOTA
Mailing Address - Street 2:SAN GERARDO
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-3470
Mailing Address - Country:US
Mailing Address - Phone:787-347-2851
Mailing Address - Fax:
Practice Address - Street 1:1700 CALLE DAKOTA
Practice Address - Street 2:SAN GERARDO
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-3470
Practice Address - Country:US
Practice Address - Phone:787-347-2851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR806103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR806OtherSCHOOL PSYCHOLOGIST