Provider Demographics
NPI:1669011417
Name:LARA, CRYSTAL DYANN (CIT)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DYANN
Last Name:LARA
Suffix:
Gender:F
Credentials:CIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32405 DIAGONAL RD
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-7503
Mailing Address - Country:US
Mailing Address - Phone:541-567-2949
Mailing Address - Fax:541-656-3046
Practice Address - Street 1:32773 W WALLS RD
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-6364
Practice Address - Country:US
Practice Address - Phone:541-567-2949
Practice Address - Fax:541-656-3046
Is Sole Proprietor?:No
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)