Provider Demographics
NPI:1821734419
Name:CHEATHAM, LARA BLAIR
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:BLAIR
Last Name:CHEATHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 W BROWARD BLVD # 100
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-1018
Mailing Address - Country:US
Mailing Address - Phone:863-521-1959
Mailing Address - Fax:
Practice Address - Street 1:3800 W BROWARD BLVD # 100
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-1018
Practice Address - Country:US
Practice Address - Phone:863-521-1959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-07
Last Update Date:2022-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW199351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical