Provider Demographics
NPI:1750836250
Name:LARA, MILI
Entity Type:Individual
Prefix:
First Name:MILI
Middle Name:
Last Name:LARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MILAGROS
Other - Middle Name:P
Other - Last Name:LARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:735 MARKET DR
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-4043
Mailing Address - Country:US
Mailing Address - Phone:630-636-6909
Mailing Address - Fax:
Practice Address - Street 1:110 E 11TH AVE
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-2704
Practice Address - Country:US
Practice Address - Phone:630-420-6332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL158103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool