Provider Demographics
NPI:1770041436
Name:LARA, LETICIA C (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:LETICIA
Middle Name:C
Last Name:LARA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 94679
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91109-4679
Mailing Address - Country:US
Mailing Address - Phone:818-314-5988
Mailing Address - Fax:
Practice Address - Street 1:236 W MOUNTAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-2969
Practice Address - Country:US
Practice Address - Phone:626-765-9150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS180931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty