Provider Demographics
NPI:1710923487
Name:JOHNSON, LARA BREED (MSW)
Entity Type:Individual
Prefix:MRS
First Name:LARA
Middle Name:BREED
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MISS
Other - First Name:LARA
Other - Middle Name:LOUISE
Other - Last Name:BREED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:7232 N HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64118-2794
Mailing Address - Country:US
Mailing Address - Phone:816-436-2325
Mailing Address - Fax:
Practice Address - Street 1:3217 BROADWAY ST
Practice Address - Street 2:SUITE 150
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-2656
Practice Address - Country:US
Practice Address - Phone:816-753-5280
Practice Address - Fax:816-753-4219
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20010117211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical