Provider Demographics
NPI:1720187578
Name:WEYLAND, LARA ADELINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARA
Middle Name:ADELINE
Last Name:WEYLAND
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5740 OLINDA RD
Mailing Address - Street 2:
Mailing Address - City:EL SOBRANTE
Mailing Address - State:CA
Mailing Address - Zip Code:94803-3542
Mailing Address - Country:US
Mailing Address - Phone:510-222-9043
Mailing Address - Fax:510-222-3508
Practice Address - Street 1:2220 MOUNTAIN BLVD
Practice Address - Street 2:SUITE 240
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-2905
Practice Address - Country:US
Practice Address - Phone:510-531-5354
Practice Address - Fax:510-222-3508
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14852103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY148520Medicaid
CAOPL148520Medicare ID - Type Unspecified
CAPSY148520Medicaid