Provider Demographics
NPI:1821302977
Name:LARA, HEATHER DANIELLE (HEATHER BENNETT, MA)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:DANIELLE
Last Name:LARA
Suffix:
Gender:F
Credentials:HEATHER BENNETT, MA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:320 N MAIN AVE STE 201D
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7242
Mailing Address - Country:US
Mailing Address - Phone:503-974-8310
Mailing Address - Fax:
Practice Address - Street 1:320 N MAIN AVE STE 201D
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7242
Practice Address - Country:US
Practice Address - Phone:503-974-8310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-31
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR390200000X
ORREGISTERED INTERN106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program