Provider Demographics
NPI:1801042569
Name:JUSTICE, LARA NATALIE (LMFT)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:NATALIE
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1891 EFFIE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-1711
Mailing Address - Country:US
Mailing Address - Phone:213-587-3336
Mailing Address - Fax:
Practice Address - Street 1:118 CARR DR APT 104
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1546
Practice Address - Country:US
Practice Address - Phone:213-587-3336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-13
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
53312106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist